Psychiatry Progress Note

(Write the entire note in a narrative, storytelling style reflecting a psychiatric assessment. Where possible, preserve the clinician's original phrasing and vocabulary from the transcript. Present content in flowing paragraphs unless otherwise specified. Rearrange the order of content where required to ensure similar themes and information are grouped together to allow for more effective communication.) Date and Time: [Date and time of the contact or review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Use format DD/MM/YYYY.) Contact Type: [Type of interaction including whether it was a telephone call, clinic review, medication follow-up, or other form of contact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a brief statement.) Participants: [Names and roles of all people present or involved in the contact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each person on a new line.) Background: [Relevant background information and reason for the contact or review, including any psychiatric diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in paragraphs of full sentences.) Psychotropic Medication: [All psychotropic medications the patient is currently prescribed, including name, dose, and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else leave this section blank and do not omit the heading. Write as a list with each medication on a new line.) Review and Discussion: [All relevant details from the review including the patient's current mental state, symptoms, and functioning, any changes since the last contact, risk issues discussed, family concerns raised, and any general discussion about current issues and next steps] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences, preserving the clinician's original phrasing and vocabulary from the transcript where possible.) Mental State Examination: [Observations of the patient's appearance and behaviour, speech and language, mood and affect, thought process and content, perceptual disturbances, suicide risk, cognitive function, and insight] (Only include elements explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Present as a single concise paragraph. Do not reuse phrasing or wording from earlier sections of the note.) Plan: [Specific actions, interventions, and next steps agreed or recommended following the contact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each action on a new line.) Follow-Up: [Details of when and how the patient will next be reviewed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a brief statement.) Summary: [A single sentence summarising the key outcome of the interaction, highlighting any significant changes or the most important next step] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a single sentence.)