[Clinic Letterhead]
123 Health Street
Wellness City, WC 45678
(123) 456-7890
(123) 456-7891
Practitioner: Dr. Thomas Kelly, MD
Surname: Smith
First Name: John
Date of Birth: 15/04/1980
PROGRESS NOTE
25 August 2024
John Smith is a 43-year-old married male who lives with his wife and two children. He works as an accountant and has been experiencing increased stress due to work-related pressures. He has a supportive family environment and actively participates in community activities.
John has a history of generalized anxiety disorder and major depressive disorder, which have been managed with a combination of sertraline and cognitive-behavioral therapy (CBT). He has been stable on his current medication regimen for the past six months, with no significant exacerbations of his symptoms.
John presented to the clinic alone today. He appeared well-groomed and was cooperative throughout the session. He maintained good eye contact and was articulate in expressing his concerns. His demeanor was calm, and he did not exhibit any signs of agitation or distress.
John reported feeling generally stable in his mood, though he occasionally experiences feelings of worthlessness and hopelessness, particularly during high-stress periods at work. He denied any thoughts of self-harm or harm to others. He also denied experiencing any paranoia or hallucinations.
John has a strong support system, including his wife and close friends. He is actively involved in his children's lives and participates in their school activities. He manages household duties effectively and receives occasional help from his wife. John is also enrolled in the National Disability Insurance Scheme (NDIS) for additional support.
John is currently dealing with mild hypertension, which is being managed by his general practitioner. He has been advised to monitor his blood pressure regularly and maintain a healthy diet and exercise routine.
Plan and Recommendations:
1. Continue current medication regimen (sertraline 100 mg daily).
2. Continue with cognitive-behavioral therapy sessions bi-weekly.
3. Maintain participation in NDIS programs.
4. Monitor blood pressure regularly and follow up with the general practitioner.
5. Schedule a follow-up visit in one month to monitor mental health stability.
John was advised to maintain a balanced lifestyle, including regular physical activity and adequate hydration. He was also encouraged to practice stress management techniques, such as mindfulness and relaxation exercises.
Dr. Thomas Kelly, MD
Consultant Psychiatrist
[Clinic Letterhead]
[Clinic Address Line 1]
[Clinic Address Line 2]
[Contact Number]
[Fax Number]
Practitioner: [Practitioner's Full Name and Title]
Surname: [Patient's Last Name]
First Name: [Patient's First Name]
Date of Birth: [Patient's Date of Birth] (use format: DD/MM/YYYY)
PROGRESS NOTE
[Date of Note] (use format: DD Month YYYY)
[Introduction] (Begin with a brief description of the patient, including their age, marital status, and living situation. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Patient’s History and Current Status] (Describe the patient’s relevant medical history, particularly focusing on any chronic conditions or mental health diagnoses. Mention any treatments that have helped stabilize the condition, such as medication or psychotherapy. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Presentation in Clinic] (Provide a description of the patient's physical appearance during the clinic visit. Include anyone who they attented the clinic with. Include observations about their appearance, demeanor, and cooperation. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Mood and Mental State] (Describe the patient's mood and mental state as reported during the visit. Include details about their general mood stability, any thoughts of worthlessness, hopelessness, or harm, and their feelings of safety and security. Also mention if the patient denied or reported any paranoia or hallucinations. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Social and Functional Status] (Discuss the patient's social relationships and their level of function in daily activities. Include information about their relationship with significant others, their participation in programs like NDIS, and their ability to manage household duties. If the patient receives help from others, such as a spouse, describe this support. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Physical Health Issues] (Mention any physical health issues the patient is experiencing, such as obesity or arthritis. Include advice given to the patient about managing these conditions, and whether they are under the care of a general practitioner or specialist for these issues. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Plan and Recommendations] (Outline the agreed-upon treatment plan based on the discussion with the patient and any accompanying individuals. Include recommendations to continue with current medications, ongoing programs like NDIS, and any other health advice provided, such as maintaining adequate water intake. Also include a plan for follow-up visits to monitor the patient’s mental health stability. You may list this part in numbered bullet points)
[Closing Statement] (Include any final advice or recommendations given to the patient. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists.)
[Practitioner's Full Name and Title]
Consultant Psychiatrist
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Ensure that every section is written in full sentences and paragraphs, capturing all relevant details in a narrative style.)
