Psychiatric Evaluation -RM

HPI

SUBJECTIVE / HPI “The patient was seen for follow-up today” and was {{AccompaniedStatus}} {{VisitType}} (include only if explicitly stated). The patient {{SymptomReporting}} experiencing {{ReportedSymptoms}}, describing their current mood as "{{QuotedMood}}" which they attribute to "{{QuotedReason}}" (include only if mentioned). Symptoms have been present for {{SymptomDuration}}, occurring with a frequency of {{SymptomFrequency}} and severity described as {{SymptomSeverity}}. The patient also {{AssociatedSymptomsPresence}} associated symptoms such as {{AssociatedSymptoms}}. They describe the impact of symptoms on daily functioning, including {{FunctionalImpact}}. Medication adherence is {{AdherenceReported}}, with {{AdherenceDetails}}. The patient {{SideEffectsPresence}} side effects from their current regimen. The patient also{{ChangesInSleepAppetiteInterestEnergyConcentrationHopelessnessHelplessnessPresence}} changes in sleep, appetite, or interests (include only if discussed). After reviewing the risks, benefits, and alternatives to medication, the patient {{MedicationDecision}} {{MedicationName}}. Substance use, including alcohol, is {{SubstanceUseReported}} (include only if discussed, if not discussed, do not mention it in the note). "Patient was provided education and counseling regarding diagnosis, prognosis, and treatment options, including the risks, benefits, and potential side effects of prescribed psychotropic medications. Patient had the opportunity to ask questions, which were answered. A safety plan was discussed, including 911, 988, visiting the ED, or urgent appointment as needed. Patient reported understanding, stated they feel safe, and agreed to the treatment and safety plan. Follow-up scheduled in {{FollowUpInterval}} or sooner if needed."

ASSESSMENT

ASSESSMENT The patient is a {{PatientAge}}-year-old {{PatientGender}} with a past psychiatric history significant for {{PsychHistory}}. On examination, thought process was linear and logical with mood congruent and {{AffectDescription}} affect. The patient’s condition has been {{StabilityStatus}} over the past {{Timeframe}}, with reported symptoms including {{KeySymptoms}}. The patient reports {{MedicationAdherenceStatus}} and {{SideEffectStatus}}, including {{SideEffectDetails}} with approximate onset of {{SideEffectTimeline}}. Differential diagnoses considered include {{DifferentialDiagnoses}}, with current medication choice based on symptom profile, tolerability, and response. The patient denies suicidal or homicidal ideation, intent or plan, and denies auditory/visual hallucinations. If any of the below were discussed, this statement will reflect that: The patient reported medical concerns including {{SpecificMedicalConcerns}}, which will be referred to their primary care provider or appropriate specialist for further evaluation. Laboratory results from {{LabDateOrSource}} were reviewed, showing {{LabFindingsSummary}}. Additional labs will be ordered if clinically indicated. The patient expressed interest in therapy for {{TherapyFocusOrReason}}, and a referral will be placed. "Patient was provided education and counseling regarding diagnosis, prognosis, and treatment options, including the risks, benefits, alternatives to, and potential side effects of prescribed psychotropic medications, and the patient reported understanding. Patient had the opportunity to ask questions, which physicians answered to the best of their abilities. A safety plan was discussed and reviewed with the patient, along with the availability of emergency resources including 911, 988/crisis hotline, going to the ED, as well as scheduling a sooner/urgent appointment if needed. They reported understanding, reported they feel safe, and were agreeable to the safety and treatment plan. Patient currently denies SI/HI/AH/VH. Patient agreeable to follow up in weeks or sooner if needed." PLAN • Continue: {{ContinueMedications}} • Start: {{StartMedications}} • Discontinue: {{DiscontinueMedications}} • Therapy: {{TherapyPlan}} • Labs: {{LabPlan}} • Follow up in {{FollowUpInterval}}

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