Follow-up
Created by
Michael Lee
Specialty
Psychiatrist
Last edited
10/20/2026
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0 times
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About this template
This psychiatric follow-up template structures documentation of ongoing care, including presenting complaints, mental status, risk, diagnoses, treatment, safety planning, and additional information. It supports consistent tracking of medication adherence, mood, cognition, and treatment progress across visits.
Preview template
24/10/2023
History of Presenting Complaints
- Persistent low mood and anhedonia, though slightly improved over the past 2 weeks. -Ongoing middle insomnia; waking up 2–3 times per night, averaging 5 hours of sleep.
- Adherent to sertraline (Zoloft®) 50 mg PO daily; takes trazodone (Desyrel®) 50 mg PO QHS PRN (~3x/week) with no reported side effects.
- Concentration remains mildly impaired at work, struggling to complete complex tasks.
Mental Status Examination
- Appearance: Casually dressed, adequate grooming, appears stated age.
- Behavior: Cooperative, calm, good eye contact, no psychomotor agitation or retardation.
- Speech: Normal rate, rhythm, and volume.
- Mood: "A bit better, still tired."
- Affect: Constricted, mood-congruent.
- Thoughts: Linear, logical, goal-directed. No delusions or obsessions.
- Perceptions: Denies auditory or visual hallucinations.
- Cognition: Alert and oriented x4. Attention and memory grossly intact.
- Insight: Good.
- Judgment: Good.
Risk Assessment
- Denies active or passive SI, intent, or plan. Denies HI. Low acute risk.
Diagnosis
- Major depressive disorder, recurrent, moderate (F33.1)
- Generalized anxiety disorder (F41.1)
- Primary insomnia (G47.00)
- Alcohol use disorder, mild, in sustained remission (F10.11)
Treatment Plan
- Increase sertraline (Zoloft®) to 100 mg PO daily. Continue trazodone (Desyrel®) 50 mg PO QHS PRN for insomnia.
- Follow up in 4 weeks.
- Order baseline lipid panel, HbA1c, and TSH prior to next visit.
Safety Plan
- Reviewed warning signs and coping strategies. Patient instructed to call 988, contact clinic, or go to the nearest ED if SI/HI develops.
Additional Notes
- Patient continues weekly CBT with external therapist; reports positive therapeutic alliance.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.