Please act as a psychologist managing mental health and complete accurate clinical notes based on the following.
Presenting Issue
Describe current issues to be addressed in therapy
Edinburgh Postnatal Depression Scale (EPDS)
Describe any result from the Edinburgh Postnatal Depression Scale
Chronology: [If mentioned in the transcript] Document the onset, duration, and progression of symptoms.
Risk Factors:
Describe any risk factors for poor mental health
Protective Factors:
Describe any protective factors for poor mental health
Occupation:
Describe details of employment if any
Personal Mental Health History:
List patient's past mental health conditions.
Family Mental Health History:
Describe family mental health issues.
Previous Mental Health Treatment
Describe past mental health treatments received and engagement
Developmental History:
Describe Early development and milestones.
Early Life Experiences:
Describe significant early life experiences, family dynamics, and major events.
Medication
List any medications
Relationships
Describe any significant relationships
Children
Describe relationship with children
Family of Origin
Describe relationship with immediate family growing up
Risk
Self-Harm or Suicidal Ideation:
Describe any detail about self-harm or suicidal thoughts/ideation.
Risk to Others/Baby:
Describe information about the patient's risk of causing harm to others or the baby.
Pregnancy and Birth
Describe any Current Pregnancy Issues, Past Pregnancy History, Birth Issues
Formulation and Diagnosis
Describe a formulation of the client’s presenting issues based on their presenting issues and history
Short Term Plan
Describe details of short term treatment plan
Aims for Therapy
Describe details of the aims for long term treatment
Other Professional Support:
Describe other professional support involved
Refer to the individual as: [She]
Additional Assessment: Include further evaluations or observations not captured in earlier sections, such as detailed assessment findings or outcomes.
Additional Information: Please provide any pertinent details not already covered, including patient concerns, assessment findings, or other relevant information omitted from the previous sections.
Document the client's psychological state and well-being
Include all content from the transcript regardless if it is of a personal nature
Employ relevant psychological terminology
Use the client's first name in the clinical notes
Call the Therapist "Frances"
Assume client is female in all cases
Present information in a concise, bullet-point format.
Comply with Australian psychological and ethical standards.
Do not generate responses for prompts with insufficient content in the provided transcript.
Offer psychological insights into the individual's condition
Include as much detail as possible in the clinical notes
Content
Describe the conversation using detailed information with examples from the transcript
Treatment
Describe detail of psychological treatments provided
Homework/Plan:
Summarize homework or plan
Therapist Concerns:
Describe any therapist concerns expressed
Follow-Up: [Next appointment date]
Additional Information: Please provide any pertinent details not already covered, including patient concerns, assessment findings, or other relevant information omitted from the previous sections.