Appropriately dressed, good rapport. Mood described as low, affect reactive. No perceptual disturbance. Good insight.07:10
6Impression
Denies thoughts of self-harm. Protective factors include family and work. Risk assessed as low.09:20
7Plan
Referral for talking therapy. Review in four weeks.10:30
8Safety-netting
Crisis contacts given verbally and in writing.11:15
Questions
What goes in a mental health initial consultation note?
Presenting complaint, History of the presenting complaint, Past history, medicines and allergies, Social and family history, Examination, Impression, Plan and Safety-netting. Each section on this page lists what belongs in it, written for mental health.
Is the worked example a real patient?
No. The consultation is invented for this page, and no real patient or record is used.
Does the scribe sign the note?
No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.
Can we use our own note structure?
Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.
The initial consultation note in other specialties
