Psychiatry Progress Note
Created by
Scott MacDonald
Specialty
Psychiatrist
Last edited
10/20/2026
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0 times
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About this template
A concise structure for documenting psychiatric follow-up visits, including interim history, mental status, physical findings, investigations, clinical impression, and plan. It supports consistent recording of explicitly documented patient information without adding unstated details.
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Interim History
34yo M attends for scheduled MDD follow-up, reporting persistent low mood and requesting a medication adjustment. Symptoms have been ongoing for 6 weeks, worst in the mornings, characterized by pervasive emptiness and rated 7/10 in severity in the context of recent job loss. Worsened by social isolation; temporarily relieved by walking the dog. Self-treated with OTC melatonin 5 mg PO QHS with minimal efficacy for sleep. Mood and energy have progressively declined over the past 2 weeks despite adherence to escitalopram (Cipralex®) 10 mg PO daily. One prior MDE in 2019, successfully managed with sertraline (Zoloft®) 100 mg PO daily and CBT, achieving full remission within 4 months. Currently struggling to complete household chores, missing job interviews, and withdrawing from friends. Associated with terminal insomnia, anhedonia, reduced appetite with a 3 kg weight loss over 1 month, and subjective psychomotor retardation. Denies SI/HI or manic symptoms.
Mental Status Examination
Casually groomed, appearing stated age, with mild psychomotor slowing; describes mood as "completely drained." Affect is constricted, dysphoric, and congruent with reported mood. Thought process is linear and goal-directed; thought content is notable for ruminations over financial security, with no delusions, phobias, or SI/HI. No observed perceptual disturbances. Insight is good, recognizing symptoms as a depressive relapse requiring treatment optimization. Judgment is intact, demonstrated by treatment adherence and safety planning. Oriented x3 with grossly intact memory, concentration, and comprehension, however, not formally assessed.
Physical Examination
A physical examination was completed, with these vital signs documented:
Height: 178 cm Weight: 74 kg HR: 68 BPM BP: 118/76 mmHg SpO2: 99 % on room air
Investigations
Labs from 12/05/2026 show TSH 2.1 mIU/L, CBC WNL, electrolytes WNL, and vitamin B12 340 pmol/L. PHQ-9 score today is 18.
Impression
Major depressive disorder, recurrent, moderate-to-severe, worsening since the previous visit due to inadequate response to low-dose SSRI and acute psychosocial stressors. Differential diagnosis includes adjustment disorder with depressed mood and bipolar II disorder (ruled out given absence of hypomanic history).
Plan
Repeat PHQ-9 and GAD-7 at next visit Increase escitalopram (Cipralex®) 20 mg PO daily; discontinue OTC melatonin and initiate trazodone (Desyrel®) 50 mg PO QHS PRN for insomnia Referred to community structured CBT program; reviewed sleep hygiene and crisis line resources Follow-up appointment scheduled for 26/06/2026 at 14:00
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