Letter Template:
For use by a psychiatrist seeing a known patient for a follow-up medication review appointment, this NovoNote template provides a structure for a detailed formal letter to be forwarded to the referrer (GP) following that appointment. It includes information captured by the Psychiatric Medication Review template, and converts this information into a structured, clinically appropriate letter.
In Australia, it would be suitable to use under MBS Item 300 or 302, and other item numbers for shorter appointments of approximately 15 minutes.
Note: If seeing a patient for the first time, it is recommended that a different template that captures more background information be used, such as the Psychiatrist Letter to Referrer – Clinical Interview / First Appointments template.
Dr Referring Clinician’s Name
Referring Clinician’s Address
Re: Patient name, DOB Patient date of birth, Patient address
Dear Referring Clinician’s Name,
Thank you for referring Patient’s Name for a psychiatric assessment review.
- Provide a brief summary of the presenting problem or purpose of the appointment, including type and nature of symptoms, length of time with symptoms, external stressors, interpersonal or relationship factors, and impact on functioning
- Detail any stated changes in mood, behaviour, or functioning since the last appointment
- Detail the patient’s perspective on the effectiveness and side effects of current treatment
- Detail any changes in life circumstances or significant life events since the last appointment
Mental Status Examination (MSE):
- Appearance: Describe the patient’s general physical appearance, hygiene, grooming, and attire
- Behaviour: Describe the patient’s interaction with their surroundings, activity level, psychomotor activity, eye contact, and rapport
- Speech: Describe the rate, volume, tone, coherence, and articulation of the patient’s speech
- Mood and Affect: Describe the patient’s reported mood and emotional state using their own words if possible, range and appropriateness of emotional response, and any discrepancies with stated mood
- Thought Process: Describe the patient’s coherence, organisation, and flow of thoughts
- Thought Content: Describe the content of the patient’s thoughts, noting presence of delusions, distortions, obsessions, or intrusive thoughts
- Perception: Describe hallucinations or other perceptual disturbances
- Cognition: Describe the patient’s orientation to time/place/person, attention, memory, concentration, and comprehension
- Insight and Judgment: Describe the patient’s understanding of their mental health condition and decision-making capacity
Diagnosis and Assessment:
- Describe the patient’s diagnosis as stated by the psychiatrist, based on DSM-5-TR and ICD-11 criteria
- Include diagnostic codes for both DSM-5-TR and ICD-11
- Detail any comorbidities or differential diagnosis considerations
- Summarise the patient’s clinical presentation and any changes from previous appointments
Current Medications:
- List all medications that the patient is currently taking, including psychotropic and non-psychotropic, with doses and frequencies
- Describe any past medication history including response, side effects, and adverse reactions
- Assess adherence to current prescribed medication regime, including any challenges
- Note any patient reported side effects or concerns about current medications
- Detail the patient’s assessment of current medication effectiveness
- Detail the psychiatrist’s assessment of the impact of current medication regime on patient’s presentation
Treatment Plan Discussed With Patient:
- Specify evidence-based recommendations for medication changes, including dosages and frequencies, and rationale
- Specify suggested non-pharmacological interventions and rationale
- Specify referrals to other specialists or services and rationale
- Detail plan for follow-up and monitoring
- Detail any Safety Plan made if patient poses risk to safety
- Summarise education provided about diagnosis and treatment options
- Summarise other recommendations made specifically to the General Practitioner
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
- Include protective factors that mitigate risk
Summary:
- Provide brief paragraph summary of the appointment
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Psychiatrist Name
Dr James Jones
NovoPsych Medical Centre
1 Station Road
Carlton VIC 3053
Re: Mary Blogs, DOB 15/08/1985, 1 NovoNote Street, Parkville VIC 3052
Dear Dr Jones,
Thank you for referring Mary Blogs for a psychiatric assessment review.
Mary presents with Major Depressive Disorder that has shown significant improvement over eight weeks since commencing sertraline therapy following marital breakdown and divorce proceedings. She reports substantial improvement in mood, sleep quality, and energy levels with resolution of severe anxiety symptoms. Mary indicates sertraline has been well-tolerated with no significant side effects, and she has successfully reduced alcohol consumption to minimal levels. Recent finalisation of custody arrangements has provided relief from legal stressors, and she has been actively engaging in weekly psychological therapy.
Mental Status Examination (MSE):
- Appearance: Well-groomed and appropriately dressed with markedly improved energy
- Behaviour: Maintained excellent eye contact and demonstrated cooperative, engaged behaviour
- Speech: Normal rate and volume without previous emotional lability
- Mood and Affect: Self-described mood as “much more stable and optimistic,” with euthymic affect
- Thought Process: Coherent and organised with no evidence of cognitive impairment
- Thought Content: No evidence of delusions, obsessions, or intrusive thoughts
- Perception: No hallucinations or perceptual disturbances reported
- Cognition: Fully oriented with intact attention, memory, and concentration
- Insight and Judgment: Excellent insight into condition and strong commitment to ongoing treatment
Diagnosis and Assessment:
Mary’s diagnosis of Major Depressive Disorder, single episode, moderate severity (DSM-5-TR: 296.22, ICD-11: 6A70.1) remains current, though symptoms have improved from moderate-severe to mild range. Secondary diagnosis of Alcohol Use Disorder, mild severity, is now in sustained remission. Clinical presentation demonstrates substantial improvement in mood, functioning, and psychological wellbeing with effective treatment response.
Current Medications:
Sertraline 50mg daily commenced 22/05/2025 with excellent adherence and no missed doses. Paracetamol used as needed for occasional headaches with minimal frequency. Mary reports no significant side effects from sertraline after initial mild nausea resolved within first week. She has successfully discontinued increased alcohol consumption that occurred during acute depression phase. Mary reports sertraline has been highly effective in improving mood, sleep, and functioning with benefits beginning around week three.
Treatment Plan Discussed With Patient:
Continue sertraline 50mg daily as current dose provides excellent therapeutic benefit with minimal side effects. Maintain weekly psychological therapy to consolidate gains and develop long-term coping strategies. Follow-up psychiatric appointment scheduled in three months to monitor progress and assess potential medication tapering. Safety planning reviewed with clear crisis contact instructions. Recommend continued GP monitoring for general health with attention to sleep hygiene and stress management.
Risk:
Mary denies suicidal ideation and reports significant improvement in hopelessness since commencing treatment. Protective factors include strong maternal attachment to children, stable employment, finalised custody arrangements, and active treatment engagement. Risk assessment indicates low risk with no concerns regarding self-harm or harm to others.
Summary:
Mary has demonstrated excellent response to treatment for Major Depressive Disorder with significant improvements in mood and functioning. Her commitment to treatment and resolution of psychosocial stressors has contributed to substantial clinical improvement. Current plan involves continuing sertraline with psychiatric monitoring and ongoing psychological support.
Thank you for your ongoing care and management. Please feel free to contact me if you have any questions.
Yours sincerely,
Dr Sarah Smith
- Template Type
- Letter
- Report
- Note Dictation
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