Sample Transcribed Reports:

Edited Sample Report

This patient is well known to you and she continues to feel depressed, sad and unhappy. She is still restless and pacing. She complains of her head feeling heavy. There hasn't been much change in her overall functioning over the past few days. So far, she is not hearing any voices. She denied any ideas of reference, passivity phenomenon or suicidal ideation.

Assessment
Major depression with psychotic symptoms/agitation.

Plan
She is advised to continue with Zoloft, 200 mg a day and risperidone, 1 mg b.i.d. and lorazepam, 0.5 mg q. h.s. I will review her at my office in a week's time. Prognosis fair.

Edited Sample Report

This patient is feeling much better. She is marginally hypomanic. She calm, relaxed and at ease. Her energy level has improved. Her concentration is good; free of any delusions; did not complain of any pain symptoms. Her sleep and appetite are good.

Assessment
Axis I -- Major depression, recurrent.
Axis II -- Deferred.
Axis III -- Fibromyalgia.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 65.

Plan
Today, I have advised this patient to continue with Serzone, 100 mg b.i.d. for one week and then increase the dosage to 150 mg b.i.d.. I will review her at my office in a month's time. She was advised to keep in touch with you for ongoing follow-up.

Edited Sample Report

This patient continues to feel quite depressed, sad, unhappy, withdrawn, apathetic, lacking energy and ambition to do much. He is still preoccupied with somatic symptoms. He is bursting into tears without any provocation. He's not sleeping well. His appetite is not good. Often he feels miserable.

Assessment
Axis I -- Major depression, recurrent. Obsessive-compulsive disorder. Dysmorphophobia.
Axis II -- Deferred.
Axis III -- No specific problems identified.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 60.

Plan
Increase Zoloft to 200 mg q. d. and Anafranil to 100 mg q. h.s. If the response is not adequate during the coming 2-3 weeks, we will arrange for his admission to the psychiatry unit at **** Hospital and consider him for a course of ETC. With the above plan of treatment, he should settle well.