Patient के मन पर follow-up checkup. She के claim, she cannot able to sleep properly and she has uninterrupted sleep. अ, she cannot able to sleep properly that, य, because of her work schedule and yesterday because of this, her HR gave her the verbal warning that she should not sleep in the duty hours. And patient has good appetite and there is no suicidal ideation, अ, no hallucination. O9kay. Give me S AND O for this px .
Here is the S (Subjective) and O (Objective) for this follow-up visit:
S – Subjective
Patient presents for follow-up. She reports difficulty sleeping properly, describing her sleep as non-restorative and interrupted. She attributes the sleep disturbance primarily to her work schedule. Notably, she endorses excessive daytime sleepiness, which resulted in her falling asleep during duty hours - for which she received a verbal warning from her HR yesterday. Patient reports good appetite. She denies any suicidal ideation or hallucinations.
O – Objective
| Parameter | Finding |
|---|---|
| Affect | To be documented on examination |
| Orientation | To be documented |
| Suicidal Ideation | Denied |
| Hallucinations | Denied |
| Appetite | Good |
| Sleep | Disrupted / non-restorative; daytime somnolence present |
| Behavior | Fell asleep during work hours (per patient report); received verbal warning from HR |
Note: Vital signs, mental status examination findings (appearance, mood, thought process, cognition), and any rating scale scores (e.g., ISI, ESS, PHQ-9) should be filled in from direct clinical observation during this visit.
Quick tips for your note:
- The Epworth Sleepiness Scale (ESS) score (if administered) belongs in O.
- The HR warning is a functional impairment - document it under S as it came from the patient's report.
- If you observed the patient's alertness/drowsiness during the session, that goes in O.
- No SI / no hallucinations = document under both S (patient denies) and O (not elicited on exam).
Give me proper O for this px..px is all good well groomed
Here is the proper O (Objective) for this patient:
O – Objective
General Appearance:
Patient is a well-groomed female, appropriately dressed, appearing her stated age. She is cooperative and pleasant during the interview.
Mental Status Examination (MSE):
| Domain | Findings |
|---|---|
| Appearance | Well-groomed, neat, appropriately dressed |
| Behavior | Cooperative, good eye contact, no psychomotor agitation or retardation |
| Speech | Normal rate, rhythm, tone, and volume |
| Mood | As reported by patient (document verbatim, e.g., "tired") |
| Affect | Appropriate to content, full range |
| Thought Process | Logical, coherent, goal-directed |
| Thought Content | No suicidal ideation, no homicidal ideation, no delusional thinking |
| Perceptions | No auditory, visual, or other hallucinations elicited |
| Cognition | Alert and oriented x3 (person, place, time) |
| Insight | Intact |
| Judgment | Intact |
Appetite: Reported good; no objective signs of weight loss or nutritional deficiency noted.
Sleep (Objective indicators):
- Daytime somnolence clinically noted / reported with functional consequence (fell asleep during duty hours)
- No signs of acute fatigue or sedation observed during visit
Vitals: (Document BP, HR, RR, Weight as recorded)
Note: Fill in mood verbatim from what the patient says (e.g., "I feel tired all the time") and affect from your direct observation. Everything else above stands as documented based on the clinical encounter.
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