Rewrite the source note into a psychiatrist-style new patient HPI and Assessment & Plan.
OVERALL GOAL:
Produce documentation that is concise, clinically synthetic, and easy to read. Preserve useful clinical detail from the source note, but compress unnecessary anecdotal or repetitive content. The result should be more concise than a transcript-style note while still retaining clinically useful nuance.
HPI:
- Start with a single sentence in this format:
“[Age] year old [male/female/patient] with a reported psychiatric history of {diagnoses reported prior to appointment during chart review by clinician and/or diagnoses reported by the patient}” and, if relevant "and relevant past medical history of..."
- Then start the HPI with a new paragraph.
- Write in narrative prose only, except where specifically instructed below for ADHD symptom review.
- Use short paragraphs with smooth transitions.
- Start the first paragraph with: “The patient reports…”
- In the opening paragraph, summarize the main presenting problem, relevant duration/course, major symptoms, functional impact, important recent stressors/context, and the patient’s reason for seeking care now.
- If the patient expressed hopes or goals for treatment, include that briefly.
- If collateral information was provided, incorporate it naturally. Do not mention the absence of collateral if none was available.
- Include additional paragraph(s) only for other clinically relevant psychiatric symptom domains that were actually discussed (for example depression, anxiety, trauma-related symptoms, mania, psychosis). Present these as narrative synthesis, not as a review-of-systems checklist.
- If sleep was discussed, include one separate paragraph specifically summarizing sleep pattern, duration, insomnia/hypersomnia, sleep quality, daytime tiredness, and other relevant sleep details.
- Do not include routine negative ROS language in the HPI unless it is clinically important.
- Do not include detailed past psychiatric, social, family, developmental, or substance history in the HPI unless directly relevant to the current presentation, diagnostic reasoning, or treatment plan.
- Prefer clinical abstraction over exhaustive detail: keep examples only when they clarify symptom severity, pattern, or impairment.
- Avoid transcript-like phrasing, redundant qualifiers, and long lists of minor examples.
ADHD EVALUATION RULE:
- If this appointment included an ADHD evaluation, after the narrative HPI paragraphs include a numbered inattentive symptom review section.
- The output must explicitly include the following questions as written below, with concise answers based on the interview:
Inattention
1. Do you often fail to give close attention to details or make careless errors? (Specifically focused on mistakes / errors / incomplete submissions)
2. Do you often fail to sustain attention in tasks and activities? (Distractibility, trailing off, etc.)
3. Do you often appear to not listen to what is being said to you? (Very specific, people having to verbally cue or snap at patient to regain their attention in conversation)
4. Do you often fail to follow through on instructions or to finish tasks? (Primarily focused on assigned tasks rather than self-generated tasks, leaving things undone. Alternatively difficulty following written instructions or procedures.)
5. Are you often impaired in organising tasks and activities? (This is more about difficulty sequencing and prioritizing activities than about being an "organized (neat) person.")
6. Do you often avoid or strongly dislike tasks that require sustained mental effort? (This is about avoidance / procrastination / dislike of mental tasks rather than earlier questions about difficulties faced with those tasks.)
7. Do you often lose things necessary for certain tasks or activities? (Self explanatory)
8. Do you often become easily distracted by external stimuli? (Self explanatory, distracted by other stimuli.)
9. Are you often forgetful in the course of daily activities? (This has more to do with the forgetfulness -- not remembering to do things, where things were placed, forgetting appointments, not checking to-do list, etc.)
- For each item, include both the direct answer if it was asked explicitly and the best supporting examples described elsewhere in the interview.
- If the source note contains relevant examples but no explicit yes/no answer, synthesize the answer from the available clinical content.
- Do not include explanatory parenthetical text after the questions.
- Keep each numbered answer concise but specific enough to show symptom pattern and functional impact.
- Do not omit any of the 9 questions when an ADHD evaluation was performed.
ASSESSMENT:
- Start with a single sentence in this format:
“[Age] year old [male/female/patient] with a psychiatric history of {diagnoses determined during this appointment}” and, if relevant "and relevant past medical history of..."
- Include only diagnoses/history that are relevant to the current evaluation.
- Follow with a new paragraph containing a brief synthesis of the current presentation:
- the most likely diagnostic framing,
- the main symptom clusters,
- key contextual or contributing factors,
- any meaningful diagnostic uncertainty or differential considerations,
- and the rationale for the treatment approach being chosen.
- Keep the assessment concise and interpretive rather than repetitive. Do not simply restate the HPI.
PLAN:
- Present the plan as clear bullet points.
- Include medications with exact dose, route, frequency, and titration instructions if provided. (e.g. - Bupropion XL 300mg PO Daily or - Sertraline 25mg PO Daily x 1 week then 50mg PO Daily)
- Include psychotherapy and other recommended interventions when relevant.
- Include clinically important counseling, monitoring, follow-up instructions, or contingency planning if discussed.
- Be exceptionally concise and focused.
- Be specific. Avoid unnecessary operational detail.
STYLE CONSTRAINTS:
- Use physician-level psychiatric documentation.
- Be concise, but not skeletal.
- Preserve nuance that affects diagnosis, severity, impairment, or treatment planning.
- Omit clutter, repetition, and low-yield anecdotal detail.
- Do not invent information.
- Do not mention that you are summarizing, rewriting, or reformatting a source note.
SUBJECTIVE / ATTRIBUTIONAL STYLE:
- Write the HPI primarily in subjective style.
- Attribute symptoms, beliefs, and historical interpretations to the patient unless they are independently established facts.
- Prefer phrasing such as:
“The patient reports…”
“The patient states…”
“The patient describes…”
“The patient feels…”
“The patient believes…”
“The patient wonders whether…”
- Do not convert patient-reported possibilities, self-suspicions, or tentative interpretations into definitive diagnostic statements.
- For example, write “The patient reports lifelong difficulty with attention and wonders whether ADHD may explain this” rather than “The patient has had ADHD their whole life.”
- Do not present diagnostic conclusions in the HPI unless they were already clearly established prior diagnoses and are directly relevant.
- Keep the HPI focused on reported symptoms, course, context, and impact rather than the clinician’s interpretation.
- Save diagnostic synthesis, differential considerations, and clinical conclusions for the Assessment section.
