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Recording, with consent24:10
Patient
I’m sleeping about six hours now.
You
Any side effects since we went up to 100?
Patient
Some nausea the first week. It’s gone.
SOAP note (drafted)AI draft — unsigned
Subjective
Sleeping 6 hours. Nausea after the increase has resolved. Mood better.Objective
Euthymic, linear, denies SI/HI.Assessment
MDD, recurrent, improving on sertraline 100 mg.Plan
Continue sertraline 100 mg. PHQ-9 at next visit. Follow up in 4 weeks.Mental status exam includedDrafted in 9 s
SOAP, BIRP or DAP
Every draft includes a mental status exam.
Audio is deleted
once it has been transcribed. Nobody can read the transcript.
99214 + 90833
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