Note Examples
Example of Psychiatry Note

Example of Psychiatry Note

SUBJECTIVE

Presentation:

  • Chief Complaint: Client presented with symptoms of depression including low mood, lack of interest in activities, low energy and motivation, and feelings of hopelessness. She reported these symptoms have been ongoing for the past several months.

Psychological Factors:

  • Previous Mental Health Treatments: Client has a past history of depression and anxiety for which she received counseling in college. She tried Lexapro in the past but stopped due to side effects.

Biological Factors:

  • Medication: Zoloft 50mg daily
  • Dosage And Frequency: 50mg taken once daily
  • Efficacy: Client reported the Zoloft has helped improve her mood and energy levels somewhat but her motivation and interest remain low. She feels the medication could be more effective.
  • Side Effects: Client reported experiencing nausea, headache, and fatigue when first starting Zoloft. These side effects have subsided.
  • Changes: No recent changes have been made to client's medication regimen.
  • Substances: Client drinks 1-2 glasses of wine 2-3 nights per week. No other substance use reported.

OBJECTIVE

Clinical Assessment:

  • Clinical Conceptualization: Client meets criteria for major depressive disorder, recurrent episode, moderate. Contributing factors include genetic predisposition, early childhood emotional neglect, and recent stresses including divorce and job loss. Protective factors include social support and willingness to engage in treatment.

Diagnosis 1:

  • Diagnosis Description: Major Depressive Disorder
  • DSM-5 Code: 296.20
  • ICD-10 Code: F33.1
  • Reasoning: Client exhibits 5 of the 9 criterion symptoms including depressed mood, loss of interest, fatigue, feelings of worthlessness, and diminished ability to concentrate and make decisions. Symptoms cause clinically significant distress and impairment.

Comorbidity: Client also exhibits symptoms of generalized anxiety disorder which exacerbates feelings of worry, tension, and fatigue. Anxiety symptoms likely interact with and worsen depressive symptoms.

Mental Status Exam:

  • Mood And Affect: Depressed mood and flat affect.
  • Speech And Language: Speech was clear and coherent with normal rate and tone.
  • Thought Process And Content: Thought process was logical and goal-directed. Thought content was focused on feelings of sadness, worthlessness, and hopelessness about the future. No evidence of delusions or obsessions.
  • Orientation: Client was oriented x3.
  • Perceptual Disturbances: No perceptual disturbances reported or observed.
  • Cognition: Concentration and memory appear intact though client reports subjective difficulties with concentration, decision-making, and motivation due to depression.
  • Insight: Insight and judgment are good. Client recognizes the need for treatment and is motivated to feel better.

Risk Assessment:

  • Risks Or Safety Concerns: Client denied current suicidal or homicidal ideation, intent, or plan. No other safety concerns noted during session.
  • Hopelessness: Client expressed feelings of hopelessness about the future and whether she will feel better again.
  • Suicidal Thoughts Or Attempts: Client denied any active or recent suicidal thoughts or attempts.
  • Self Harm: No current self-harm behaviors were reported.
  • Dangerous To Others: Client denied thoughts or intentions of harming others.
  • Quote (Risk): “Sometimes I feel like I'll never be happy again. I just feel stuck."
  • Safety Plan: No safety plan was developed as client denied suicidal intent. Client's ex-husband will remove firearms from home.

Interventions:

Therapeutic Interventions

  • Validated client's feelings of sadness, hopelessness and loss of interest
  • Provided psychoeducation about depression symptoms and treatments
  • Discussed pros and cons of increasing medication dosage.

ASSESSMENT

Progress And Response:

  • Response To Treatment: Client has shown limited response to medication and therapy interventions. Her mood, motivation, and interest remain depressed though she is beginning to have more hope treatment can help.

PLAN

Follow Up Actions And Plans:

  • Plan For Future Session: Next session will focus on monitoring medication changes and continuing motivational enhancement techniques.
  • Plans For Continued Treatment: Client will contiune on Zoloft 50mg Once Daily and to be discused next visit to increase Zoloft dosage. Client will attend weekly therapy sessions with therapist.
  • Coordination Of Care: Therapist was consulted prior to this session about the possibility of increasing session frequency.