Example #1

Month/Day/Year            Psychology Note
Time:  1600

Patient was interviewed to assess current memory function and hospital adjustment with the MMSE, the Geriatric Depression Scale (GDS) and the Type D Questionnaire.  Patient was pleasant, cooperative and attentive throughout the interview and fully participated in completing all tasks.  Patient scored within normal limits on the memory and concentration tasks.  Patient did not report anxiety or depressive symptoms.  Patient reports some difficulty adjusting to the hospital and but negative affect and social inhibition as reported on the Type D indicates no major adjustment difficulties.  The scores indicate the patient is not having significant difficulties adjusting to their medical condition though additional assessment may be warranted.  Patient scored a 2 on the GDS indicating no major depressive symptoms. Patient does not appear to be experiencing significant psychological distress at this time. 

XXXXXX XXXXXXX - PA Student
Supervisor:  Dr. Jeff Baker, Chief Psychologist

Example #2

Month/Day/Year            Psychology Note
1545

Patient was interviewed to assess current memory function, hospital adjustment and depression with the MMSE, the Type D Questionnaire and the Geriatric Depression Rating Scale.  Patient was having difficulty with attention and memory as demonstrated with the MMSE.  Patient is also having difficulty with adjustment and reports significant symptoms of depression as reported by the GDS. Patient may benefit from additional monitoring of mood.  Dr. Baker will be notified for possible additional consultation and treatment.