For use by a psychiatrist seeing a known patient for a follow-up or general review appointment, this NovoNote template provides a structure for a formal letter to be forwarded to the referrer (GP) following that appointment. It includes information captured by the Psychiatric General Review template, and converts this information into a structured, clinically appropriate letter.
In Australia, it would be suitable to use under MBS Item 293, and other item numbers for appointments of approximately 30 minutes.
Dr Referring Clinician’s Name
Referring Clinician’s Address
Re: Patient name, DOB Patient date of birth, Patient address
Dear Referring Clinician’s Name,
Thank you for referring Patient’s Name for a psychiatric assessment review.
Mental Status Examination (MSE):
Current Medications:
Psychometric Testing:
Diagnosis and Assessment:
Risk:
Treatment Plan Discussed With Patient:
Summary:
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Psychiatrist Name
Dr James Jones
NovoPsych Medical Centre
1 Station Road
Carlton VIC 3053
Re: Mary Blogs, DOB 15/08/1985, 1 NovoNote Street, Parkville VIC 3052
Dear Dr Jones,
Thank you for referring Mary Blogs for a psychiatric assessment review.
Mary presents with Major Depressive Disorder that has shown significant improvement over eight weeks since commencing sertraline therapy following marital breakdown and divorce proceedings. She reports substantial improvement in mood, sleep quality, and energy levels with resolution of severe anxiety symptoms prominent during initial assessment. Mary indicates sertraline has been well-tolerated with no significant side effects, and she has successfully reduced alcohol consumption to minimal levels. Recent finalisation of custody arrangements has provided considerable relief, and she has been actively engaging in weekly psychological therapy.
Mental Status Examination (MSE):
Mary presented as well-groomed with markedly improved energy compared to her initial assessment. She maintained excellent eye contact, demonstrated cooperative behaviour, and spoke with normal rate and volume without previous emotional lability. Her self-described mood was “much more stable and optimistic,” with euthymic affect and coherent thought processes. She demonstrated excellent insight into her condition and strong commitment to ongoing treatment.
Current Medications:
Diagnosis and Assessment:
Mary’s diagnosis of Major Depressive Disorder, single episode, moderate severity (DSM-5-TR: 296.22, ICD-11: 6A70.1) remains current, though symptoms have improved from moderate-severe to mild range. The secondary diagnosis of Alcohol Use Disorder, mild severity, is now in sustained remission. Clinical presentation demonstrates substantial improvement in mood, functioning, and psychological wellbeing with effective treatment response.
Risk:
Mary denies suicidal ideation and reports significant improvement in hopelessness since commencing treatment. Protective factors include strong maternal attachment to her children, stable employment, finalised custody arrangements, and active treatment engagement. Risk assessment indicates low risk with no concerns regarding self-harm or harm to others.
Treatment Plan Discussed With Patient:
Summary:
Mary has demonstrated excellent response to treatment for Major Depressive Disorder with significant improvements in mood and functioning. Her commitment to treatment and resolution of psychosocial stressors has contributed to substantial clinical improvement. Current plan involves continuing sertraline with psychiatric monitoring and ongoing psychological support.
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Sarah Smith
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