18 entries · Last updated 24 Jul 2026, 16:40 by Dr. E. Carter
Progress note24 Jul 2026 · 16:40
Routine follow-up appointment
Patient reports improved sleep and mood stability since last review. Continues to engage well with weekly therapy sessions...
Dr. E. Carter — Consultant Psychiatrist
Mental State Exam10 Jul 2026 · 11:15
MSE completed at outpatient review
Appearance appropriate, mood euthymic, affect reactive. No abnormal perceptions elicited. Insight and judgement intact...
Dr. R. Osei — Registrar
Risk assessment10 Jul 2026 · 11:05
Risk review — no acute concerns
No current suicidal ideation or intent. Historic self-harm three years ago, currently low risk. Protective factors remain strong...
Dr. R. Osei — Registrar
Referral letter2 Jun 2026 · 09:30
Referral to Clinical Psychology
Referred for CBT input to support ongoing management of low mood and anxiety symptoms alongside pharmacological treatment...
Dr. E. Carter — Consultant Psychiatrist
Showing 4 of 18 entries
Patient attended clinic accompanied by partner. Reports mood has been stable over the past four weeks, rating 7/10 on average. Sleep has normalised to 7 hours per night. Denies any thoughts of self-harm or suicide. Engaging well with weekly CBT and finds strategies helpful for managing intrusive thoughts...
Suicide & self-harmHistoric self-harm 2023, none since
Violence & aggressionNo history of violence recorded
Self-neglectLives with partner, managing daily tasks
Vulnerability / exploitationNo current safeguarding concerns
AbscondingReviewed at last outpatient visit
Diagnosis
ICD-11 code
Type
Date added
Status
Recurrent depressive disorder, current episode moderate
6A71.1
Primary
14 Jan 2024
Active
Generalised anxiety disorder
6B00
Secondary
3 Mar 2024
Active
Insomnia disorder
7A00
Secondary
2 Jun 2025
Resolved
Medication
Dose
Route
Frequency
Start date
Status
Sertraline
100mg
Oral
Once daily
14 Jan 2024
Active
Mirtazapine
15mg
Oral
At night
3 Mar 2024
Active
Zopiclone
3.75mg
Oral
As required
2 Jun 2025
Discontinued
Rx #20260724-01 · Sertraline 100mg, 28 tabs
Issued 24 Jul 2026 by Dr. E. Carter
Sent to pharmacy
Rx #20260724-02 · Mirtazapine 15mg, 28 tabs
Issued 24 Jul 2026 by Dr. E. Carter
Sent to pharmacy
Rx #20250602-04 · Zopiclone 3.75mg, 7 tabs
Issued 2 Jun 2025 by Dr. R. Osei
Collected
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Attached documents (3)
GP_referral_letter.pdf
312 KB · Uploaded 24 Jul 2026 by Dr. E. Carter
Discharge_summary_scan.jpg
1.1 MB · Uploaded 12 Jun 2026 by Admin Team
Consent_form_signed.pdf
204 KB · Uploaded 14 Jan 2024 by Dr. E. Carter
Test
Result
Units
Reference range
Flag
Date
Sodium
138
mmol/L
135–145
Normal
18 Jul 2026
TSH
5.9
mIU/L
0.4–4.0
High
18 Jul 2026
Haemoglobin
11.2
g/dL
13.0–17.0
Low
18 Jul 2026
White cell count
6.1
x10^9/L
4.0–11.0
Normal
18 Jul 2026
Lithium level
0.6
mmol/L
0.6–1.0
Normal
18 Jul 2026
3 results outside reference range · flagged for clinician review
Clinical Psychology — CBT input
Sent 2 Jun 2026 by Dr. E. Carter · Reason: low mood & anxiety
Acknowledged
Endocrinology — thyroid function review
Sent 20 Jul 2026 by Dr. E. Carter · Reason: raised TSH