Patient Details:
- [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [patient age] (only include patient age if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [patient gender] (only include patient gender if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [date of evaluation] (only include date of evaluation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Physical Appearance:
- [describe overall appearance, grooming, attire, and hygiene as specific as possible] (only include describe overall appearance if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any distinctive physical traits or signs of neglect] (only include note any distinctive features if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Behavioral Observations:
- [describe motor activity, eye contact, and cooperation level as specific as possible] (only include describe general behavior if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any unusual movements or mannerisms, signs of agitation or restlessness] (only include note any unusual movements or mannerisms if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Verbal Communication:
- [describe speech rate, volume, fluency, and tone as specific as possible] (only include describe speech rate, volume, and tone if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any abnormalities such as slurring, rapid speech, or long pauses] (only include note any speech abnormalities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Emotional State:
- [describe patient's self-reported mood as specific as possible] (only include describe patient's self-reported mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any observed mood] (only include note any observed mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Emotional Expression:
- [describe observed emotional state, range and appropriateness of affect as specific as possible] (only include describe range and appropriateness of affect if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note if the affect is congruent with the reported mood] (only include note any incongruence with mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Cognitive Processes:
- [describe thought process and content, including any delusions or obsessions, as specific as possible] (only include describe thought process if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any thought content abnormalities, signs of disorganized thinking or unusual beliefs] (only include note any thought content abnormalities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Sensory Perception:
- [describe any hallucinations, perceptual disturbances, or illusions, as specific as possible] (only include describe any hallucinations or illusions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any derealization or depersonalization, especially related to all sensory modalities such as visual, auditory, tactile, etc.] (only include note any derealization or depersonalization if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Cognitive Function:
- [describe orientation to time, place, and person, also memory, attention, and concentration, as specific as possible] (only include describe orientation to time, place, and person if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any orientation, memory, attention, or concentration issues] (only include note any memory or attention issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Self-awareness:
- [describe patient's awareness of their condition and need for treatment as specific as possible] (only include describe level of insight into condition if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any discrepancies in insight, especially if they don't understand their mental health issues] (only include note any discrepancies in insight if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Decision-making:
- [describe judgment, decision-making ability, and understanding of consequences in hypothetical situations as specific as possible] (only include describe judgment in hypothetical situations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically note any observed judgment issues, especially related to their ability to make safe and responsible decisions] (only include note any observed judgment issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Counselor Details:
- [counselor name] (only include counselor name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [counselor credentials] (only include counselor credentials if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [date of report] (only include date of report if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)