As an example, here's a note that Lindy generated s/p system prompt engineering but without any other input from me. All I did was upload the transcript and give the patient's name and age. Only edits here are to protect confidentiality:
Subjective:
E is a 37 year old female who presented for psychiatric follow up. She recently started a new job working in patient access at a medical office, checking patients in and verifying insurance. She finds the work easy so far but worries it may become boring. She took this position to have an income as she prepares for her upcoming wedding in one month, which she is very excited about. Wedding planning has been a source of stress, with many vendors to communicate with and payments to make. After the wedding, she plans to move in with her new husband and rent out her current home.
Mood:
E describes her mood as "pretty good overall", "positive", and "occasionally stressed". She is surprised at how well she is handling multiple major life stressors and changes simultaneously, noting "10 years ago I would be like a mess." While not everything about the wedding planning has gone perfectly, she feels the positives far outweigh the negatives. She still experiences some negative feelings but is "just kind of dealing with it."
Sleep:
Over the past 6 months, E has intermittently been waking around 2am and having difficulty falling back asleep for about 3 hours. This occurs about once every 10 days. She has noticed a correlation between this sleep disturbance and having more than one alcoholic drink in the evening. In an effort to reduce alcohol intake, she has gone from 6-7 drinks per week to 3-4. The sleep issue has only occurred once in the past 2 weeks since starting her new job, which requires an earlier wake time. When it does occur, she feels "kind of tired" the next day but is still able to function.
Substance Use:
As noted above, E has reduced her alcohol intake from 6-7 drinks per week to 3-4 drinks per week, in part because she noticed a correlation between drinking more than 1 drink and waking in the night. She is also motivated to reduce alcohol in case she becomes pregnant.
Medications:
E continues to take bupropion XL 300mg daily and escitalopram 20mg daily. She denies any adverse effects from these medications.
Therapy:
E continues to see her therapist weekly, although has missed the last 2 sessions due to scheduling difficulties with her new job. She hopes to figure out a new therapy schedule soon.
Stressors:
E's elderly cat was recently diagnosed with another age-related illness. She has been anticipating his passing for a couple years now and finds it to be "kind of just the constant anticipatory grief." She gives him medication daily and assesses that he still has an adequate quality of life. However, she feels very conflicted, stating "please just die because I've been mentally preparing for his death for so long...this is torture and at the same time I'm like, please don't die because he was my first pet and he means a lot." The timing of his decline has been challenging with everything else she has going on.
Relevant Psychosocial Factors: E is getting married in one month and feeling excited but also stressed by the planning process. Many family members are having big emotional reactions to the wedding that E is having difficulty relating to. After the wedding, she will be moving in with her husband and attempting to rent out her current home. She is also grieving the anticipated loss of her elderly cat.
Mental Status Examination (MSE):
Appearance: well-groomed, appears stated age
Behavior: cooperative and engaged
Motor: no abnormal movements noted
Speech: normal rate, rhythm, volume and prosody
Mood: "pretty good overall"
Affect: bright, reactive, full range
Thought Process: linear, goal-directed, coherent
Thought Content: future-oriented, no SI/HI or psychotic symptoms
Cognition: grossly intact per interview
Insight/Judgment: good insight, judgment intact
Objective:
Vitals: Not obtained at this visit.
Collateral Information: None obtained.
Assessment:
E is a 37 year old female who presented for ongoing medication management and supportive therapy in the context of multiple life stressors, including starting a new job, getting married in one month, moving, and caring for her terminally ill elderly cat. Despite these challenges, she presents with a bright affect and reports her mood is generally positive, which she notes is a marked change from how she would have coped with this level of stress in the past. She has made efforts to reduce her alcohol intake, which seems to have had a positive impact on the intermittent middle insomnia she was experiencing. She continues to find her medication regimen of bupropion XL 300mg and escitalopram 20mg daily to be effective without adverse effects. Therapy sessions have been helpful for her but she has missed a few appointments recently due to scheduling issues. Overall, E demonstrates good insight and judgment, as well as adaptive coping skills during this time of transition and anticipatory grief. Ongoing pharmacotherapy and psychotherapy is indicated for maintenance of her current stability.
Plan:
- Continue current medication regimen of bupropion XL 300mg daily and escitalopram 20mg daily
- Encourage continued therapy with current provider, assisting in problem-solving scheduling issues
- Supportive discussion around stress management techniques and self-care practices during this busy time
- Process anticipatory grief related to elderly cat's condition as needed
- Refill medications for 90 days to allow time to find new provider if needed due to insurance changes
- Return to clinic in 8 weeks, tentatively scheduled for 5/31 at 1:30pm
*****
There are still aspects of this I'm unhappy with (consolidating the Stressors and Psychosocial Factors section for a start) and the plan is wordier and has more boilerplate supportive therapy suggestions than I would ever actually write. So there's a ways to go. Still, this was literally the result of clicking record, uploading a file, and pressing a button. I couldn't find any significant errors or hallucinations, not ideal but if I had to sign off on it unedited I wouldn't be ashamed to have my name attached to it or anything. Sophisticated formulation it is not but good enough to go on.