Sertraline (Zoloft)
Active
50mg · morning · indication: anxiety / depression
Consultation editor
Chart Note
SOAP · Follow-upS Sleep improved after CBT homework; residual worry before meetings.
O Affect brighter. PHQ-9 today: 8 (was 14 at intake).
A / P Continue weekly CBT · keep Sertraline · review goals from Jul 25.
This note sits on today’s encounter and stays linked in the patient timeline.
Medications
Medications from earlier visit
Jul 25 · 2 / 2
Sertraline (Zoloft)
Active
50mg · started Jul 18 · same dose
Mental Status Exam
AffectBrighter
MoodImproved
SleepFair
InsightGood
MSE from earlier visit
Jul 25 · 2 / 2
AffectAnxious
MoodLow
SleepPoor
InsightFair
Risk Assessment
Low
No SI/HI today. Safety plan remains on file from Jul 18.
Risk from earlier visit
Jul 25 · 2 / 2
Moderate
Elevated worry · safety plan reviewed.
Treatment Plan
From earlier visits ▾Active · CBT continuity · Version 3 / 3
- Problems / goals carried from Jul 18 & Jul 25
- Adherence 68% · 2 problems · 3 goals · 5 objectives
- Focus: anxiety reduction & sleep routine
Session 3 builds on session 2
Switch tabs, then open Earlier visits—exactly how continuity works in the consultation editor.
Switch tabs, then open Earlier visits on Medication, MSE, or Risk.
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