Here is a comprehensive, ready-to-use Mental Health Clinical Case Presentation Template designed for rounds, supervision, case conferences, or handoffs. I’ve structured this for maximum clarity and clinical utility.

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OPTION 1: The Comprehensive Case Presentation

(Use for: Initial evaluations, formal rounds, training seminars, complex consultations)

1. Header Information

• Patient ID: Initials, Age, Gender, Ethnicity
• Date of Evaluation:
• Presenter: Your name/role
• Setting: Inpatient/Outpatient/Crisis/Emergency
• Referral Source: Who referred and why?

2. The "One-Liner" (Elevator Pitch)

Summarize the case in 1-2 sentences:

"34-year-old female with history of Bipolar I disorder presenting with 2-week manic episode characterized by decreased sleep, grandiosity, and psychosis, precipitated by antidepressant monotherapy."

3. Chief Complaint (CC)

• Patient’s own words in quotes: "I haven't slept in days and the FBI is watching me"
• Duration of current episode

4. History of Present Illness (HPI)

Structure using OLDCARTS adapted for psychiatry:

• Onset: When did symptoms begin? Acute vs. insidious?
• Location/Context: Where do symptoms occur? (Home, work, specific triggers?)
• Duration: Continuous vs. episodic? Frequency?
• Characteristics: Specific symptoms (mood, thought content, perceptions, cognition)
• Aggravating/Alleviating: What makes it worse/better? (Substances, stress, sleep)
• Rating: Severity (0-10 scale, functional impact)
• Timeline: Chronological narrative of this episode
• Treatment to Date: What’s been tried this episode? (Meds, therapy, hospitalizations)

Key Psychiatric Review of Systems:

• Mood/affect changes
• Anxiety/panic
• Psychosis (SX, delusions, disorganization)
• Trauma/PTSD symptoms
• Eating disorder behaviors
• Suicidal/Homicidal ideation (save detailed risk for later section)

5. Past Psychiatric History

• Previous diagnoses (with dates)
• Prior hospitalizations (when, where, why, length)
• Previous suicide attempts (lethality assessed)
• Outpatient treatment history (therapists, psychiatrists)
• Treatment Response History: What worked? What failed? (Crucial for planning)

6. Medical History

• Chronic illnesses (especially thyroid, diabetes, neurological, autoimmune)
• Current medical problems
• Obstetric/Gynecologic: Pregnancy status, postpartum history (crucial for mood episodes)
• Hospitalizations/Surgeries

7. Medications (Current & Recent)

• List all with doses, duration, adherence, side effects
• Specifically note: Recent changes (last 3 months), PRN use
• Include supplements/herbals

8. Substance Use History

• CAGE-AID or AUDIT results if available
• Timeline of use (current vs. past)
• Last use (withdrawal risk?)
• Impact on psychiatric symptoms

9. Family Psychiatric History

• 3-generation pedigree if relevant
• Suicide, bipolar, schizophrenia, substance use, anxiety disorders
• Method of suicide in relatives (increases risk)

10. Social History (The "Seven Domains")

1. Support System: Who is in their life? Quality of relationships?
2. Living Situation: Safe? Stable? Who with?
3. Occupational/Educational: Working? Disability? Financial stressors?
4. Developmental: Childhood, trauma history (ACEs), attachment style
5. Cultural/Spiritual: Cultural norms affecting illness expression, religious community
6. Legal: Pending charges, forensic history, custody issues
7. Strengths/Resilience Factors: What keeps them going? Coping skills?

11. Mental Status Exam (MSE) (Current State)

12. Risk Assessment (Dedicated Section)

• Suicide: Ideation, plan, intent, means, protective factors, history
• Homicide/Violence: Thoughts, targets, access to weapons, history
• Vulnerability/Abuse: Elder/child abuse, financial exploitation, trafficking
• Self-neglect: Ability to care for basic needs

13. Formulation (The "Why" and "How")

Use a Biopsychosocial or 5-P model:

Biological:

• Genetics/family history
• Neurodevelopmental factors
• Medical comorbidities
• Substance effects

Psychological:

• Defense mechanisms
• Attachment style
• Cognitive patterns
• Trauma history
• Personality factors

Social/Cultural:

• Stressors (relationships, finances, discrimination)
• Cultural explanatory model of illness
• Systemic barriers (housing, insurance, racism)

Summary Sentence: "This is a [age] [gender] with [predisposing factors] who developed [disorder] precipitated by [trigger], perpetuated by [maintaining factors], resulting in [functional impairment]."

14. Differential Diagnosis

List 3-5 most likely, with reasoning:

1. Primary: Most likely diagnosis with supporting evidence
2. Alternative: What else could explain this? (Medical mimics, other psychiatric)
3. Rule Out: Conditions requiring further data

15. Assessment & Diagnosis

• Primary Diagnosis: ICD-10/DSM-5-TR codes
• Secondary diagnoses
• Medical conditions impacting presentation

16. Plan (Problem-Oriented)

For each active problem:

Problem 1: [Primary Diagnosis]

• Pharmacologic: Specific drug, dose, duration, target symptoms, monitoring plan
• Psychotherapeutic: Modality (CBT, DBT, psychodynamic), frequency, focus
• Social: Case management, housing, vocational rehab, legal aid
• Safety: Observation level, contract, means restriction counseling

Problem 2: [Medical Comorbidity]

• Referrals, monitoring

Problem 3: [Risk Factor]

• Safety planning, crisis resources

17. Disposition/Prognosis

• Level of care needed (inpatient, PHP, IOP, outpatient)
• Anticipated trajectory
• Barriers to treatment

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OPTION 2: The "Bullet Rounds" Template

(Use for: Morning rounds, brief check-ins, handoffs)

Patient: [Initials, Age]
The Story: [One-liner]
Overnight Events: [Changes, interventions, incidents]
Vitals/Meds: [Relevant only]
MSE Today: [Key changes from baseline]
Risk: [Current level, any changes]
Task List: [What needs to happen today?]
Barriers: [What's blocking discharge/improvement?]

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Pro Tips for Effective Presentations

Do's:

• Lead with the diagnosis if you know it, or the chief concern if you don't
• Humanize early: One personal detail (e.g., "avid gardener," "devoted father") prevents "chart talk"
• Highlight data gaps: "We still need collateral from the sister regarding manic symptoms"
• Anticipate questions: If labs are pending, say when they'll be back
• Bring it back to function: Always connect symptoms to "How does this affect their life?"

Don'ts:

• Don't read the chart verbatim—synthesize
• Don't bury the lede: If they're suicidal, say it in the first 30 seconds
• Don't skip the formulation—this shows your clinical reasoning
• Don't present without knowing: Allergies, current meds, and last attempt/violence history

For Virtual Presentations:

• Send de-identified photos/artwork only if clinically relevant and consented
• Have labs pulled up screen-share ready
• Mute non-speakers

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Quick-Start Checklist

Before presenting, confirm you have:

• Age, legal status (voluntary/involuntary/conservatorship)
• Allergies (especially to meds)
• Substance use status (withdrawal risk?)
• Current suicidal/homicidal status
• Collateral contact made (Y/N)?

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To customize this further for you:

1. What is your clinical setting? (Academic medical center, community mental health, private practice, emergency department?) This changes what supervisors expect to hear.

2. What is your discipline/training level? (Psychiatry resident, psychology intern, social work student, attending?) I can adjust the depth of formulation expected.

3. Is this for a specific type of case? (First episode psychosis, complex trauma, child/adolescent, geriatric, addiction focus?) I can provide specialty-specific addendums.

What setting are you presenting in, and would you like me to tailor this for a specific patient population or time limit (e.g., 10-minute vs. 30-minute presentation)?

Mental Health Clinical Case Presentation Template

This template is based on standard formats used in psychiatry, psychology, and behavioral health settings (e.g., from University of Washington Psychiatry Consultation Line, UNC Family Medicine, and RAMS Inc.). It's designed for oral presentations (e.g., rounds, consultations, conferences) or written reports/PowerPoint slides. Aim for 5-10 minutes oral delivery or 2-4 pages written.

Key Principles Before Starting:

• De-identify: Use initials, age range (e.g., "mid-30s"), or "Patient X". Never include names, MRNs, or specifics that could identify.
• Be concise yet thorough: Focus on relevant details; chronological narrative in HPI.
• Structure logically: History → Exam → Formulation → Plan.
• Practice: Time yourself; start with positives/abnormalities.
• Visuals for PPT: Use 1 slide per major section; timelines for HPI, tables for MSE/family history.

Step-by-Step Guide to Using This Template

1. Gather Data: Review chart notes, interview patient/collaterals, complete MSE.
2. Outline First: Bullet points per section → Expand to narrative.
3. Formulate: Summarize biopsychosocial factors, DSM-5/ICD-11 diagnosis, differentials.
4. Rehearse: Present to a colleague; note questions.
5. Customize: Add setting-specific elements (e.g., reason for consult in telepsych).

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1. Identifying Information (10-20 seconds / 1 slide)

• Age/gender/pronouns: e.g., "JM, 28-year-old non-binary individual"
• Source of referral: e.g., "Self-referred to outpatient clinic"
• Informant: e.g., "Patient and sister"
• Clinical role/contact: e.g., "Seen by LCSW x3 sessions; consult for psychiatrist"

2. Chief Complaint (10 seconds)

• In patient's words: e.g., "'I can't stop worrying; my mind races all night.'"

3. History of Present Illness (HPI) (1-2 minutes / 1-2 slides)

• Onset/duration/precipitants: When did symptoms start? Acute/chronic?
• Symptoms: Use SIGECAPS for depression, etc. Severity, frequency, impact (work/sleep/relationships).
• Course/treatment trials: Prior therapies/meds, response/side effects.
• Associated factors: Suicidality, trauma, stressors.
• Example: "Symptoms began 6 months ago after job loss. Reports low mood 80% of days, anhedonia, 15lb weight loss, insomnia (4hrs/night). No SI/HI. Trial sertraline 50mg x4 weeks → partial improvement."

4. Past Psychiatric History (30 seconds)

• Prior diagnoses/episodes/hospitalizations.
• Treatments: Meds (dose/duration/response), therapy (type/#sessions).
• Suicide attempts/gestures/SA risks.
• Example: "Dx: GAD age 22. OPD tx 2018-2020 (CBT). No psych hosp."

5. Past Medical/Surgical History & Medications/Allergies (20 seconds)

• Relevant PMH: e.g., "Hypothyroidism, migraines."

• Current meds: List with doses.

• Allergies/adherence: e.g., "NKDA. Compliant."

• Table format for PPT:

  Medication	Dose	Duration	Response
  Levothyroxine	100mcg QD	2 yrs	Stable TSH

6. Family History (20 seconds)

• Psychiatric/medical in 1st-degree relatives.
• Example: "Mother: Panic disorder. Father: EtOH use. Sibling: None known."

7. Social History (30 seconds)

• Living situation/occupation/education/support.
• Substance use: Tobacco/EtOH/drugs (CAGE-AID screen).
• Legal/developmental/abuse/trauma.
• Cultural factors: e.g., "Recent immigrant from Mexico; strong family ties."
• Example: "Single, unemployed barista. Lives alone. Cannabis 1g/week x2yrs. No legal issues."

8. Mental Status Examination (MSE) (1 minute / 1 slide)

• Use standard categories; highlight abnormals first.

• Table format:

  Category	Findings
  Appearance/Behavior	Disheveled, poor eye contact, fidgety
  Speech	Normal rate/volume/tone
  Mood/Affect	Depressed mood; constricted affect
  Thought Process/Content	Linear; no delusions
  Perception	No hallucinations
  Cognition	AOx3; MMSE 28/30
  Insight/Judgment	Fair/poor
  SI/HI/Risk	No active SI; low risk

9. Diagnostic Formulation/Summary (1 minute / 1 slide)

• Biopsychosocial summary: 2-4 sentences integrating above.
• Primary Dx: DSM-5/ICD-11 with specifiers.
• Differentials: Rule-outs.
• Risk assessment: Suicidality, violence, etc.
• Example: "28yo with new-onset MDD moderate, likely triggered by job loss on background of FHx anxiety and cannabis use. Rule out bipolar II (no hypomania). Low suicide risk."

10. Plan & Questions (30-60 seconds)

• Pharmacotherapy: e.g., "Start sertraline 50mg → 100mg."
• Therapy: e.g., "Refer CBT 12 sessions."
• Labs/consults/follow-up: e.g., "TSH, ETOH screen. F/U 2wks."
• Your questions: e.g., "Best initial med? Therapy adjuncts?"
• Prognosis: Good/fair/poor rationale.

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Tips for Success

• Time Management: Practice full run-through.
• Engage Audience: "Any questions on HPI?" transitions.
• Common Pitfalls: Avoid jargon overload; too much history (stick to relevant).
• Tools: Use Timeline.js for HPI chronology; MSE templates from apps like Quenza.
• References: Cite DSM-5, guidelines (e.g., APA for depression).

This template will help you deliver clear, professional presentations. Download as a Google Doc/PPT from sources like Slidesgo for visuals.

Next Steps: What type of presentation is this for (oral rounds, written report, PPT)? Do you have a specific case (e.g., depression, psychosis) or need an example filled out? Any particular focus like child/adult/trauma?