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Templates, Clinical notes, Mental health

Mental health initial consultation note template

A mental health initial consultation note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Initial consultation note

TemplateMental health

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Mental health initial consultation note

1Presenting complaint

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.

2History of the presenting complaint

  • Presenting difficulties, their duration and their effect on daily life.
  • Sleep, appetite, energy and concentration.

3Past history, medicines and allergies

  • Previous mental health history, treatment and response.
  • Current medicines, alcohol and substance use, and allergies.

4Social and family history

  • Occupation, smoking, alcohol and anything else relevant to the complaint.
  • Family history where it changes risk or management.

5Examination

  • Mental state examination, covering appearance, behaviour, speech, mood, thought, perception and insight.

6Impression

  • Risk assessment, covering risk to self and others, with protective factors.
  • The working formulation.

7Plan

  • Treatment options discussed and agreed.
  • Crisis plan, with contacts the patient can use out of hours.

8Safety-netting

  • Crisis contacts given, and when to use them.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Initial consultation note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Mental health initial consultation note

1Presenting complaint

  • Low mood for two months with poor sleep.00:40

2History of the presenting complaint

  • Functioning at work. Withdrawn socially.02:30

3Past history, medicines and allergies

Completed by the clinician from the record.

4Social and family history

Completed by the clinician from the record.

5Examination

  • 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

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

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

All clinical notes
  1. Private GPPrivate GP initial consultation note
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  3. AestheticsAesthetics initial consultation note
  4. FertilityFertility initial consultation note
  5. PhysiotherapyPhysiotherapy initial consultation note
  6. DentalDental initial consultation note
  7. Longevity medicineLongevity medicine initial consultation note

Further reading

  1. ProductThe AI medical scribe for clinics
  2. Read nextWho signs an AI clinical note, and how to review it
  3. Read nextSOAP and specialty note templates for an AI scribe
  4. RegulatorThe CQC compliance hub

Come back to the note, written and ready to sign.

See the wai scribe write a mental health initial consultation note on your own structure, in a 15 minute video call.

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