Session Note Template:
For use by a psychiatrist seeing a previously known patient for a medication review appointment, this NovoNote template provides focused information on the patient’s medication circumstances and overall progress.
Note: For initial assessments, the Psychiatric Clinical Interview and Assessment template is recommended, or the Psychiatric General Review template for general review consultations for previously known patients.
Identifying Information:
- Detail the patient’s name or initials, age, gender, and date of today’s consultation
Diagnosis and Clinical Concerns:
- List all known diagnoses and key clinical concerns
Reason for Consultation:
- State that this is a medication review
- Include brief statement giving context to the reason for medication review
- Include information on patient’s progress since last appointment, including improvements, challenges, and observations
Mental Status Examination (MSE):
Provide a short paragraph of no more than four sentences summarising the client’s presentation using standard MSE domains: appearance, behaviour, speech, mood and affect, thought process, thought content, perception, cognition, and insight and judgment. Only include each domain if explicitly mentioned in the transcript or contextual note.
Current Medications:
- List current psychiatric and non-psychiatric medications, including doses and frequencies
Notes on Current Medications:
- Assess adherence to prescribed medication regime, including any challenges
- Note patient reported side effects or concerns about medications
- Detail patient’s assessment of medication effectiveness and changes to symptoms
- Detail patient’s concerns or issues about taking current medications
- Detail psychiatrist’s assessment of impact of current medication regime on patient’s presentation
- Include feedback from psychiatrist on patient’s self-report of medication effectiveness
Plan (Including Changes to Medication):
- Detail recommended changes to medication, including dose adjustments, changes in medication, or discontinuation
- Provide rationale for these recommendations
- Detail any further lab tests, physical health monitoring, or referrals required in relation to medication regime
- Detail any education or information provided to patient regarding medication changes
- Detail any other non-medication recommendations with rationale
- Detail plan for patient follow-up including next appointment details and appointments with other health professionals
Risk:
- Make risk assessment statement regarding suicidal or homicidal ideation, self-harm or harm to others, and risk of relapse
- Include information about past suicide attempts or self-harming behaviour
- Include psychosocial stressors contributing to risk level
- Describe protective factors that mitigate risk
Identifying Information:
- Patient: Mary B., 32-year-old female
- Consultation date: 20/06/2025
Diagnosis and Clinical Concerns:
- Major Depressive Disorder, single episode, moderate severity
- Alcohol Use Disorder, mild severity (in remission)
Reason for Consultation:
Medication review following six weeks of sertraline treatment to assess effectiveness and consider dose adjustment. Mary reports continued improvement in mood and functioning with successful resolution of custody arrangements.
Mental Status Examination (MSE):
Mary presented as well-groomed with improved energy compared to previous appointments. She maintained good eye contact, demonstrated cooperative behaviour, and described her mood as “much better, more like my old self.” Thought processes were coherent and organised with excellent insight into her condition and treatment progress.
Current Medications:
- Sertraline 50mg daily (commenced 22/05/2025)
- Paracetamol as needed for headaches (minimal use)
Notes on Current Medications:
- Excellent adherence to sertraline with no missed doses
- No significant side effects reported, initial mild nausea resolved after first week
- Patient reports marked improvement in mood, energy, sleep quality, and overall functioning
- Assessment confirms significant clinical improvement with reduction in depressive symptoms from moderate-severe to mild range
Plan (Including Changes to Medication):
- Continue sertraline at current dose of 50mg daily given good response with minimal side effects
- No additional laboratory tests required currently
- Recommend continuation of weekly psychology sessions and maintenance of lifestyle improvements
- Follow-up appointment scheduled in eight weeks to monitor continued progress
Risk:
Mary denies any suicidal ideation and demonstrates significant improvement in hopelessness since commencing treatment. Protective factors include strong maternal bond with children, stable employment, finalised custody arrangements, and active treatment engagement. Risk assessment indicates low risk status with no identified risk of self-harm or harm to others.
- Template Type
- Session Note
- Note Dictation
Share
What NovoNote Users Say
See how mental health professionals have transformed their practice with NovoNote.
