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Sample Transcribed Reports:


Psychiatry . . . Page 1


These reports are samples of basic clinical evaluations of patients seen by a psychiatrist. The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.


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Edited Sample Report

This patient is feeling quite well. He is calm, relaxed and at ease. His mood is euthymic. His energy level is good. His concentration is good. Cognitive functioning is intact. No hallucinations or delusions noted. His sleep and appetite are good. He is free of any suicidal ideation.

Assessment
Major depression, recurrent.

Plan
I have advised this patient to continue with the Serzone 300 mg b.i.d., Rivotril 0.5 t.i.d. and Trazodone, 100 mg q. h.s.

He is advised to keep in touch with you for ongoing follow-up. I will review him at my office in 6-8 weeks' time. Prognosis good.

Edited Sample Report

This patient is feeling much better. He feels calm, relaxed and at ease. His mood has improved. His concentration is good. His energy level is good. His cognitive functioning is intact. No obsessions, compulsions or phobias noted. His sleep and appetite are good.

Assessment
Axis I -- Panic disorder in remission. Major depression has improved.
Axis II -- Avoidant personality, improved.
Axis III -- Essential tremor improved.
Axis IV -- No stressors identified.
Axis V -- GAF is about 70.

Plan
Today, I have advised this patient to increase Paxil to 20 mg q. h.s. Continue with Rivotril 0.25 mg b.i.d.. He is advised to keep in touch with you for ongoing follow-up and renewal of his medications. I will review him at my office in 6-8 weeks' time.

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Edited Sample Report

This patient is feeling better, but he still hears voices. Sometimes the voices talk to him while he's at work. From time-to-time, the patient notices an increase in the frequency and intensity of these voices. However, he knows this is abnormal and is able to cope with the stress of hearing the voices.

Current Mental State
This patient is alert and responsive. His orientation is full for time, place and person. Mood is euthymic. Energy level is good. His concentration is not good. He does experience hallucinations. No delusional ideas noted. Sleep and appetite are fair.

Assessment
Schizophrenia, paranoid type.

Plan
Increase risperidone to 2 mg twice a day and Zoloft, 300 mg q.d. I will review him at my office in two weeks' time.

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