Subjective:
- Reasons for visit
- Duration/timing/location/quality/severity/context of complaint
- List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness
- Progression: how the symptoms have changed over time
- Previous episodes: any past occurrences of similar symptoms, when they occurred, how they were managed, and the outcomes
- Impact on daily activities: how the symptoms affect the patient’s daily life, work, and activities
- Associated symptoms: any other symptoms that accompany the reasons for visit & chief complaints
Past History:
- Contributing factors including past psychiatric and relevant medical history, investigations, treatments, relevant to the reasons for visit and chief complaints
- Social history that may be relevant to the reasons for visit and chief complaints
- Family history that may be relevant to the reasons for visit and chief complaints
- Other: Any other relevant information
Objective:
Mental state examination findings (only include if stated in the transcript)
- Appearance: Describe the patient’s clothing, hygiene, and any notable physical characteristics
- Behaviour: Observe the patient’s activity level, interaction with their surroundings, and any unique or notable behaviors
- Speech: Note the rate, volume, clarity, and coherence of the patient’s speech
- Mood: Record the patient’s self-described emotional state, using their own words if possible
- Affect: Describe the range and appropriateness of the patient’s emotional response during the examination, noting any discrepancies with the stated mood
- Thoughts: Assess the patient’s thought process and content, noting any distortions, delusions, or preoccupations
- Perceptions: Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient
- Cognition: Describe the patient’s memory, orientation to time/place/person, concentration, and comprehension
- Insight: Describe the patient’s understanding of their condition and symptoms, noting any lack of awareness or denial
- Judgment: Describe the patient’s decision-making ability and understanding of the consequences of their actions
- Investigations with results
- Psychometric assessments
Assessment:
Only include if stated in the transcript.
- Likely diagnosis
- Differential diagnosis
Plan:
- Assessments planned
- Treatment planned
- Relevant other actions, such as counselling or referrals
