Psychiatry Consult

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm.

Assessment:
Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed.

Plan:
Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Psychiatry Consult

Chief Complaint: [Brief statement of the primary reason for referral or consultation]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]



Past Psychiatric History:
(hyphenated list)
- [Previous diagnoses, dates]
- [Past psychiatric hospitalizations: reason, date, duration]
- [Prior therapies or counseling modalities]
- [History of self-harm or suicide attempts]

Past Medical History:
(hyphenated list)
- [Chronic medical conditions]
- [Surgeries or significant illnesses with dates]
- [Neurological events if relevant]

Medications:
(hyphenated list)
- [Name, dose, frequency, start date]
- [PRN medications if any]

Allergies:
(hyphenated list)
- [Allergen – reaction]

Family History:
(hyphenated list)
- [Psychiatric disorders in first-degree relatives]
- [Other relevant medical conditions]

Social History:
(hyphenated list)
- [Living situation and support system]
- [Occupation/education status]
- [Substance use: alcohol, tobacco, recreational drugs]
- [Legal issues if any]
- [Cultural or spiritual factors impacting care]

Mental Status Examination:
(hyphenated list)
- Appearance: [e.g., grooming, attire]
- Behaviour: [e.g., eye contact, psychomotor activity]
- Speech: [rate, volume, articulation]
- Mood: [patient’s self-report]
- Affect: [range, congruence]
- Thought process: [e.g., coherent, tangential]
- Thought content: [e.g., delusions, suicidal ideation]
- Perception: [e.g., hallucinations]
- Cognition: [orientation, memory, attention]
- Insight and judgment: [level]

DSM-5-TR Diagnosis:
- Primary diagnosis: [DSM-5-TR diagnostic code and name]
- Justification: [Concise clinical reasoning referencing specific symptoms, duration, and impairment criteria per DSM-5-TR]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[One-sentence patient summary including age, sex, and primary DSM5 diagnosis]

(hyphenated plan items)
- [Risk assessment if mentioned]
- [Treatment goals if mentioned]
- [Medication changes or initiations if mentioned]
- [Psychosocial interventions if mentioned]
- [Follow up plan if mentioned]