Mental health clinical case presentation template

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Mental health clinical case presentation template

Use this compact, stepwise template you can copy/paste and fill in quickly (5–10 min for a 5–10 min presentation).

One-line snapshot: age/sex, key diagnosis, acute reason for presentation (1–2 sentences).
Presenting problem: onset, duration, severity, triggers, current symptoms and functional impact.
Relevant history: psychiatric (past diagnoses, hospitalizations, suicidality), medical, medications/adherence, substance use.
Social/developmental/family: living, supports, occupation, child/adolescent milestones, family psychiatric history.
Mental Status Exam: appearance, behavior, speech, mood/affect, thought form/content, perception, cognition, insight, judgment.
Risk assessment: suicide/homicide/self-harm risk, protective factors, plan/intent/access to means.
Differential diagnoses and ruling-in/out evidence.
Formulation (1–2 sentences): concise biopsychosocial explanation linking history to presentation.
Treatment plan: immediate actions (safety plan, meds changes), short-term goals, psychotherapies, referrals, follow-up timeline.
Attachments/scorecards: PHQ-9, GAD-7, labs, consent. End with one-line prognosis/next steps.

Do you need this in a slide-ready or SOAP-note format?

GPT-5 Mini

Mental health clinical case presentation template

Use this compact, stepwise template you can copy/paste and fill in quickly (5–10 min for a 5–10 min presentation).

One-line snapshot: age/sex, key diagnosis, acute reason for presentation (1–2 sentences).
Presenting problem: onset, duration, severity, triggers, current symptoms and functional impact.
Relevant history: psychiatric (past diagnoses, hospitalizations, suicidality), medical, medications/adherence, substance use.
Social/developmental/family: living, supports, occupation, child/adolescent milestones, family psychiatric history.
Mental Status Exam: appearance, behavior, speech, mood/affect, thought form/content, perception, cognition, insight, judgment.
Risk assessment: suicide/homicide/self-harm risk, protective factors, plan/intent/access to means.
Differential diagnoses and ruling-in/out evidence.
Formulation (1–2 sentences): concise biopsychosocial explanation linking history to presentation.
Treatment plan: immediate actions (safety plan, meds changes), short-term goals, psychotherapies, referrals, follow-up timeline.
Attachments/scorecards: PHQ-9, GAD-7, labs, consent. End with one-line prognosis/next steps.

Do you need this in a slide-ready or SOAP-note format?

Claude 4.5 Sonnet

Mental health clinical case presentation template

Here's a concise, actionable template for a mental health clinical case presentation. Use it as a script outline: prepare 1-2 slides per section, speak clearly for 5-10 minutes, and practice timing.

1. Patient Identifiers

Age, gender, occupation, marital status (e.g., "25-year-old single male engineer").

2. Presenting Complaint (PC)

Chief issue in patient's words, onset/duration (e.g., "Low mood and poor sleep for 3 months").

3. History of Presenting Illness (HPI)

Symptoms (mood, thoughts, behavior), precipitants, course, impact on functioning.

4. Relevant Histories

Past psych/medical/surgical, medications, substance use, family psych history, social (support, stressors).

5. Mental Status Exam (MSE)

Appearance, speech, mood/affect, thought form/content, perception, cognition, insight/judgment.

6. Formulation

Summary: Biopsychosocial model, differentials, likely diagnosis (DSM/ICD).

7. Plan

Investigations, pharmacotherapy, therapy, follow-up, risk management.

Start by gathering notes from the chart/interview, then fill sequentially. Rehearse with a timer.

What format is your presentation in (e.g., PowerPoint, oral rounds, or journal club)?

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