I need a psychiatric progress note regarding a patient with PPH: of Depression, Anxiety and Insomnia . It cannot be similar, Thank you.
Here below I leave you a sample.
CC: "I feel better in the morning with my medicines "
Patient is a XXXX y/o, female with Past Psychiatric History of Depression, Anxiety and Insomnia was seen today on telehealth platform for follow up and medication treatment who alleges getting better with the last treatment of trazodone 50mg at bedtime and mirtazapine 7.5mg at bedtime, she reports decrease symptoms of sadness ,loneliness, depression , hopelessness, as well as she expresses feeling motivated, optimistic and with more energy in the morning, improve mood, self-esteem and affect because she feels useful ,decreased anxiety and stressing over her personal problems, restlessness, nervousness, as result decreased difficulty falling asleep because sleeping better and more hours at night with her previous treatment the melatonin 5mg at bedtime, also in the morning she waking up rested after a night's sleep. Patient denies side effects of the medications, suicidal and homicidal ideation, no visual or auditory hallucinations, agitation, psychotic symptoms or paranoia .Follow up in 4 weeks.