Behavioral Health Hospital Note
Patient Name: Reyes Bayer
Date: October 8, 2050
Patient ID: 123456
Attending Physician: Dr. [Your Name]
Diagnosis: Major Depressive Disorder, Moderate (F32.1)
Location: Behavioral Health Unit
Subjective:
The patient reports feeling "overwhelmed and hopeless" over the past week. He states, "I can't see a way out of this." He has experienced increased difficulty sleeping, with only 3-4 hours of sleep per night. The patient denies suicidal thoughts but expresses feelings of worthlessness. He indicates he has lost interest in activities he once enjoyed, including playing basketball and spending time with friends.
Objective:
Appearance: The patient appears disheveled and is wearing unkempt clothing.
Mood/Affect: Affect is flat; mood is reported as "sad."
Speech: Speech is slow but coherent; no pressured speech noted.
Thought Process: Logical but negative; fixated on feelings of hopelessness.
Insight/Judgment: Insight is poor; judgment appears intact.
Assessment:
A major depressive episode, moderate.
Symptoms are consistent with previous evaluations.
Treatment adherence: the patient is currently taking prescribed medications but admits he sometimes forgets doses.
Plan:
Continue current medication regimen (Sertraline 100 mg daily).
Increase the frequency of individual therapy sessions to twice a week.
Initiate group therapy for social support.
Monitor sleep patterns and consider adding a sleep aid if insomnia persists.
Schedule a follow-up appointment in one week to assess progress and medication effectiveness.
Signature:
Dr. [Your Name], MD
Behavioral Health Unit
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