Documenting a psychiatry round
Inpatient progress notes with the mental state examination and risk, discharge summaries, GP letters and family updates.
Day six of an inpatient admission
Day six, voluntary admission for a major depressive episode.
Sleeping five to six hours, up from three. Eating more, going to groups.
Casually dressed, good eye contact, speech normal rate and volume. Mood low, affect more reactive than on admission. No psychotic features.
Passive death wish on admission, none for three days, no plan or intent. Talking about her daughter's wedding in December.
MADRS 24 today, 34 on admission.
Sertraline up from 100 to 150 today, mirtazapine 15 at night continues. Day leave with her husband on Saturday.
Progress
Day 6, voluntary admission, major depressive episode. Sleep 5 to 6 h (3 h on admission). Appetite improving. Attending groups.
Mental state
Casually dressed, good rapport and eye contact. Speech normal rate and volume. Mood low; affect more reactive than on admission. No psychotic features.
Risk
Passive death wish on admission; none for 3 days. No plan or intent. Future-oriented (daughter's wedding in December). Assessed risk reduced from admission.
Measures
MADRS 24 (34 on admission).
Plan
- Sertraline increased 100 to 150 mg
- Mirtazapine 15 mg nocte continues
- Day leave with husband Saturday
Leave, discharge and the letters after
- Discharge summary
- The episode, the medication changes with doses, the risk assessment at discharge and the follow-up booked.
- Letter to the GP
- What to prescribe, what to monitor and the date of the first outpatient review.
- Family update
- Only with her consent: the plan, the warning signs and who to call after hours.
