Example Outpatient Progress Note

Subjective: The patient reports improved mood, sleep, and appetite, but energy remains low. The patient denies any side effects of medications other than mild nausea that has been diminishing over the past few days. The patient's spouse reports increased interest in usual activities. Objective: The patient is casually dressed with good grooming. Speech is more spontaneous but output is still decreased. Mood remains depressed, but improved from the previous visit. Affect is brighter, but still constricted. Thinking is logical and goal directed. The patient denies any recent suicidal or homicidal ideation. No psychotic symptoms are noted. Cognition is grossly intact. Insight is improving, and judgment remains good.

Assessment: Major depression is improving with nefazodone (Serzone) and supportive psychotherapy, but the patient still has symptoms after 4 weeks of treatment at 200 mg bid.

Plan: Increase nefazodone from 200 mg bid to 200 mg q AM and 400 mg qhs. Continue weekly supportive therapy. Refer to senior center for increased social interaction.

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