AI Scribe for Psychiatrists

📝HPI:

• Patient reports moderate improvement in anxiety symptoms with use of CBT techniques.
• Describes mood as "less on edge".
• Sleep remains fragmented, approx. 6 hours/night with multiple awakenings.
• Continues to experience mild morning drowsiness from Sertraline, reports it is tolerable.
• Denies SI/HI/AVH.

🧠PAST PSYCHIATRIC HISTORY:

• Diagnosed with Generalized Anxiety Disorder 2 years ago.
• Previous trial of Escitalopram discontinued due to GI side effects.
• No psychiatric hospitalizations.
• No history of suicide attempts.

🏥MEDICAL HISTORY:

• Hypothyroidism, well-controlled on levothyroxine.
• Migraine headaches, infrequent.
• No surgeries or hospitalizations.

💊CURRENT MEDICATIONS:

• Sertraline 50mg PO daily
• Levothyroxine 75mcg PO daily
• Sumatriptan 50mg PO PRN for migraine

⛳ALLERGIES:

• Penicillin - rash
• Escitalopram - nausea, diarrhea

🚬SUBSTANCE USE HISTORY:

• Denies current alcohol use.
• No history of illicit substance use.
• No tobacco use.
• Caffeine: 1-2 cups of coffee daily.

👪FAMILY HISTORY:

• Mother with history of depression.
• Maternal aunt with bipolar disorder.
• No family history of suicide or substance use disorders.

🔍MENTAL STATUS EXAM:

• Appearance: Casually dressed, well-groomed.
• Behavior: Cooperative, maintains good eye contact.
• Mood: Reports "less anxious", appears euthymic.
• Affect: Congruent, full range.
• Speech: Normal rate, rhythm, volume.
• Thought Process: Linear and goal-directed.
• Thought Content: No delusions, obsessions, or compulsions reported. Denies SI/HI.
• Perception: Denies hallucinations.
• Cognition: Alert and oriented x4. Grossly intact.
• Insight: Good.
• Judgment: Good.

📊ASSESSMENT SCALES:

• GAD-7 score: 8/21 (previously 14/21)
• PHQ-9 score: 5/27 (previously 7/27)
• ISI (Insomnia Severity Index): 12/28 (moderate insomnia)

📋ASSESSMENT:

• Generalized Anxiety Disorder (F41.1): Improving, tolerating Sertraline well despite mild drowsiness.
• Insomnia (G47.0): Persistent, likely related to GAD.

🧠BIOPSYCHOSOCIAL:

• Biological: Possible genetic predisposition given family history. Hypothyroidism well-controlled.
• Psychological: Responds well to CBT techniques. Developing improved coping strategies.
• Social: Reports good support system with spouse and friends. Employed full-time with manageable stress levels.

⛳RISK ASSESSMENT:

• Suicide risk: Low. No current ideation, intent, or plan. No history of attempts.
• Homicide risk: None. No violent ideation or history.
• Self-harm risk: None reported or observed.
• Overall safety assessment: Patient is stable and safe to continue outpatient treatment.

📝PLAN:

• Continue Sertraline 50mg daily. Discussed drowsiness, patient finds it manageable.
• Reinforce sleep hygiene techniques.
• Continue weekly CBT, focus on relaxation techniques.
• RTC in 4 weeks.
• 99213 - E/M code appropriate for visit complexity and time.

📋ORDERS & REFERRALS:

• TSH, Free T4 to monitor thyroid function.
• Consider referral to sleep specialist if insomnia persists despite optimization of anxiety treatment.

🚨CRISIS PLAN:

• Patient instructed to contact office during business hours for worsening symptoms.
• After hours: Call crisis line or present to nearest emergency department if experiencing thoughts of self-harm.
• Patient verbalizes understanding of plan and agrees to follow.