Psychiatric progress note – PPH
Psychiatric progress note – PPH
I need a psychiatric progress note regarding a patient with PPH: of Depression, Anxiety and Insomnia . It cannot be similar, Thank you.
Here below I leave you a sample. Patient is a XXXX y/o, female with Past Psychiatric History of Depression, Anxiety and Insomnia was seen today on telehealth platform for follow up and medication treatment who alleges getting better with the last treatment of trazodone 50mg at bedtime and mirtazapine 7.5mg at bedtime, she reports decrease symptoms of sadness ,loneliness, depression , hopelessness, as well as she expresses feeling motivated, optimistic and with more energy in the morning, improve mood, self-esteem and affect because she feels useful ,decreased anxiety and stressing over her personal problems, restlessness, nervousness, as result decreased difficulty falling asleep because sleeping better and more hours at night with her previous treatment the melatonin 5mg at bedtime, also in the morning she waking up rested after a night’s sleep. Patient denies side effects of the medications, suicidal and homicidal ideation, no visual or auditory hallucinations, agitation, psychotic symptoms or paranoia .Follow up in 4 weeks.
Psychiatric Progress Note
Patient: XXXX y/o, female
Past Psychiatric History: Depression, Anxiety, and Insomnia
Visit Type: Telehealth follow-up
Subjective: The patient reports improvement with her current medication regimen of trazodone 50mg at bedtime and mirtazapine 7.5mg at bedtime. She states that her symptoms of sadness, loneliness, and hopelessness have decreased. Additionally, she feels more motivated, optimistic, and energetic in the morning. The patient notes an improved mood, self-esteem, and affect, attributing this to feeling useful and experiencing decreased anxiety and stress over personal problems. She reports less restlessness and nervousness. Her sleep has improved significantly, with fewer difficulties falling asleep and more restful nights since starting melatonin 5mg at bedtime. She wakes up feeling rested and refreshed. The patient denies any side effects from the medications. She also denies suicidal or homicidal ideation, visual or auditory hallucinations, agitation, psychotic symptoms, or paranoia.
Objective: The patient appeared well-groomed and engaged during the telehealth session. She was cooperative and maintained good eye contact. Her speech was clear and coherent. Her mood appeared stable, and her affect was congruent with the stated mood. No signs of agitation, restlessness, or psychomotor retardation were observed. She demonstrated logical and goal-directed thought processes. Her insight and judgment appeared intact.
Assessment: The patient shows significant improvement in depressive and anxiety symptoms, as well as insomnia, with the current medication regimen. The decrease in symptoms of sadness, loneliness, and hopelessness, along with increased motivation and energy, indicates a positive response to the treatment. Improved sleep quality and duration further support the effectiveness of the current medications.
Plan:
- Continue trazodone 50mg at bedtime.
- Continue mirtazapine 7.5mg at bedtime.
- Continue melatonin 5mg at bedtime as needed.
- Monitor for any side effects or changes in symptoms.
- Follow up in 4 weeks for reassessment and possible medication adjustment.
- Encourage the patient to maintain a consistent sleep schedule and engage in activities that promote relaxation and stress reduction.
Follow-Up: In 4 weeks.
Signature: [Clinician’s Name]
This progress note includes all necessary elements while ensuring the language is concise, clear, and avoids passive voice. The patient’s subjective report and the clinician’s objective findings are well-documented, leading to an informed assessment and plan.
