Bipolar Disorder

Please feel free to either copy and paste the template below, or you can download it at the link below.

Let me know if you have any updates or corrections.

**Start of Template**

Assessment:
Patient presents with symptoms consistent with bipolar disorder, including episodes of mania characterized by elevated mood, increased energy, decreased need for sleep, and impulsivity, alternating with episodes of depression featuring low mood, fatigue, and anhedonia. Differential diagnoses include Major Depressive Disorder, Schizoaffective Disorder, ADHD, Substance-Induced Mood Disorder, and Personality Disorders.

Plan:
Initiate medication management with mood stabilizers (e.g., lithium, valproate) or atypical antipsychotics, monitoring for side effects and efficacy. Begin cognitive-behavioral therapy to support mood regulation and coping strategies. Educate the patient and family about bipolar disorder and the importance of adherence to treatment. Schedule a follow-up in 2-4 weeks to assess response to treatment and make adjustments as necessary. Evaluate for suicidal ideation and ensure a safety plan is in place, while encouraging lifestyle modifications such as regular sleep patterns, exercise, and avoidance of alcohol and drugs. Document any changes in symptoms at the next visit.

**End of Template**

Scroll to Top