In the fast-paced day-to-day life of a psychiatrist, we are consistently tasked with maintaining accurate and comprehensive records of patient interactions. One of the essential tools aiding this process is the Psychiatry Progress Note. Designed to save time and ensure organized note-taking that is compliant with medico-legal and billing standards, a well-structured template can be invaluable for both new and experienced psychiatrists.

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I'll show you what to include in your psychiatry progress note, and give you an example template you can copy and paste.
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Psychiatry Progress Note-Writing Styles

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Psychiatric notes often follow one of two predominant styles or a mix of both:

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• Narrative Style: This approach weaves a coherent story, especially in the history of the present illness section. While it offers a clear picture, it can become lengthy. It is also challenging to write this style of note if concurrently documenting during a session.

• Bullet-Point/Checklist Style: A concise method that lists relevant information. While efficient, especially in EMRs, it can oversimplify symptoms and make notes clunky.

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A balanced note will combine both styles effectively, tailoring the approach based on the writer's preference and the note's purpose.

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Guidelines for Effective Note-Writing

To perfect the art of note-writing:

• Utilize brief patient quotes judiciously.

• Document to meet any requirements insurance companies and your practice have established.

• Clearly state the rationale for changes in medication or treatment.

• Use the most detailed diagnostic code possible. Vague codes will be rejected by insurance.

• Make sure to review and edit anything carried forward from a prior note.

• Cite where history came from if it was not taken from you directly.

• Complete the note as soon as possible after the visit is over or during the visit.

• Seek feedback and continuously refine your note-writing skills.

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Note Etiquette

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When drafting notes:

• Follow the principle: If you wouldn't feel comfortable having a patient read it or wouldn't say it to a patient in a session, don't include it in your note.

• Remember that under the 21st Century Cures Act, patients have a right to see their records promptly upon request, even psychotherapy records.

• Avoid documenting intimate personal details unless clinically relevant. Concise statements like “Family issues discussed” are preferable to detailed paragraphs that multiple stakeholders might misinterpret or misuse against the patient or clinician.

• If you want to keep more detailed information elsewhere for your own recollection or supervision, have “process notes” kept separately from the patient’s chart.

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What should I include in my Psychiatry Notes?

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When it comes to note-writing in psychiatry, you want to capture a comprehensive clinical picture of the patient. Include the following elements within your notes:

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1. Identifying Information: Begin with the patient's name, date of birth, and where the patient is located at the time of the visit to ensure compliance with licensing regulations. EHRs will pre-populate some of this for you.
2. Chief Complaint: Draft a concise statement capturing the patient's main reason for seeking care. This can be a quote by the patient or a few words about the main issues addressed.
3. History of Present Illness (HPI): Detail the patient's psychiatric symptoms, including their duration, severity, and any triggers. This may include a psychiatric Review of Systems.
4. Therapy Component: If the session includes therapy, document the time spent on therapy, the therapeutic methods used, and the general themes discussed.
5. Past Psychiatric History: If this is an initial visit, provide a brief overview of the patient's psychiatric background, including previous diagnoses, treatments, hospitalizations, family history, and responses to past treatments. This does not need to be included in follow-up notes unless pertinent.
6. Medical and Surgical History: If this is an initial visit, document relevant medical and surgical information to identify potential contributing factors. For follow-ups, document any pertinent changes.
7. Medications and Allergies: List all medications, including over-the-counter drugs and supplements, and any known allergies or adverse reactions. Document adherence, side effects, and what the medications are prescribed for.
8. Mental Status Examination (MSE): A comprehensive observation of the patient's general appearance, behavior, speech, mood, affect, thought content, cognition, orientation, and insight.
9. Vital Signs and Physical Examination: If the visit included any measurement of vitals signs or any relevant physical exam findings, be sure to document them.
10. Data: If measurement-based care was used, include the most recent scores on the rating scales. Also, include any recent lab values or studies that were reviewed.
11. Assessment and Diagnosis: Provide an updated assessment that includes a differential or working diagnosis, justifying your conclusions with evidence from the evaluation. This is where information about medical decision-making can be included and documentation of the medical necessity of the treatment being provided.
12. Risk Assessment and Plan: Provide an assessment of the risk level of the patient towards themselves and others, any changes in the level of risk, relevant risk factors and protective factors, and planning around managing risk.
13. Treatment Plan: Summarize the short and long-term goals, interventions, therapies, medications, and other referrals. Include specific dosages, durations, monitoring parameters, and rationale behind chosen treatments.
14. Time Spent and Followup: Document how much face-to-face time was spent and how much time was spent outside of the session (including documenting!). Indicate when the next follow-up appointment should be scheduled.

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What is a Psychiatry Progress Note Template?

A Psychiatry Progress Note Template serves as a standardized tool for psychiatrists. Used in appointments following the initial consultation, it provides a structured format for documenting a patient's progress, observations, and any changes in treatment or diagnosis. These notes offer invaluable insights when evaluating a patient's journey, especially in long-term treatments.

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How to Write a Psychiatry Progress Note

• Standardized Format: Using a consistent format ensures all critical details are included and easily located. The SOAP note is often the most common for psychiatrists’ visits.

• Objective Observations: Document observable facts rather than subjective opinions. This ensures accuracy and reduces potential biases. Mental status exam findings, physical exam findings, vital signs, and data such as the results of measurement-based care scales or lab values belong in the objective section.

• Medical Decision Making: Any changes in medication, therapy, or other treatments should be meticulously recorded along with the rationale. Like a math problem, you need to “show your work.”

• Risk Assessment: Psychiatrists are not expected to have a crystal ball but it is essential to demonstrate how you are evaluating the patient’s overall risk to themselves and others and what steps have been taken to minimize risk as much as is reasonable.

• Patient's Feedback: It's helpful to include the patient's own feedback and perspective on their progress and treatment. If the patient disagrees with your recommendations, document this and consider adding the “interactive complexity” code.

• Time Documentation: Make sure to include the start and end time of face-to-face time with the patient as well as any other time spent that day doing work related to the visit and provide details. If psychotherapy was included as part of the visit, set aside a portion of the note (such as within the HPI) to document time spent on psychotherapy, the themes discussed and the type of approaches used.

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Psychiatry Progress Notes Template Example

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Feel free to copy and paste this as a template for your progress notes:

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SUBJECTIVE:

Met Patient: via HIPAA Compliant Zoom from patient’s home. Patient has consented to telehealth treatment and is aware of possible compromises in HIPAA compliance. Clinician is licensed in state patient is located.

Location of Patient: home with camera on State: NY

Present in Session: Patient

CC/Reason for Visit: followup visit for these psychiatric concerns: depression

HPI:

Discussed stress at work and recent COVID infection (now resolved). Feels antidepressant is helping with mood and wife commented to him last week he seemed in better spirits

Therapy approach, subject and time spent on therapy:

Approximate Psychotherapy Time: 16 Minutes

Psychotherapy Code: 90833 (16-37 minutes) w/ E/M

Focus of Therapy: Work stress

Therapeutic approach: Psychodynamic

PSYCHIATRIC ROS:

DEPRESSIVE/NEUROVEGETATIVE: Depression Status: Improving

• decreased motivation
• interrupted sleep
• early AM awakening
• decreased appetite
• diurnal variation, worse in morning
• impaired functioning due to depressive symptoms at work

MANIA: did not endorse

ANXIETY: did not endorse

TRAUMA: did not endorse

OCD Spectrum Symptoms: did not endorse

PSYCHOSIS: did not endorse

DISORDERED EATING: did not endorse

ADHD: did not endorse

AUTISM SPECTRUM: did not endorse

ODD/CONDUCT/ANTISOCIAL: did not endorse

PERSONALITY DISORDER TRAITS:  did not endorse

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OBJECTIVE:

MENTAL STATUS EXAM

Appearance:

Dress: appropriate

Grooming: adequately groomed

General Appearance: adequately nourished , appears consistent with stated age

Behavior: cooperative and pleasant

Eye Contact: normal

Psychomotor: normal movement, position, posture

Speech: normal rate, rhythm, volume and prosody

Mood: euthymic

Affect: full range and congruent

Thought Process: coherent, linear, logical and goal directed

Thought Content: unremarkable, future oriented, non-psychotic

Safety: no suicidal, homicidal or violent ideation towards others

Insight: good

Judgment: good

Cognition: Memory: no apparent deficits

Measurement Based Care

Completed the following rating scales and reviewed scores:

PHQ-9: 8  which is consistent with Mild Depression (prior score 15)

PHQ-9 Ranges

0-4:  No Depression

5-9: Mild Depression

10-14: Moderate Depression

15-19: Moderately Severe Depression

20 or higher: Severe Depression

For reference: A  PHQ-9 score ≥10 has a sensitivity of 88% and a specificity of 88% for major depression.

Pertinent Labs/studies/external records: TSH from one week ago is WNL

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ASSESSMENT:

Depression improving

Risk: Safety risk is chronically increased overall given multiple dynamic risk factors including current insomnia,  being under financial strain,   and static risk factors including  MDD diagnosis, family member with completed suicide, mitigated by protective factors including  actively making future plans, verbalizing hope for the future, feeling attached to life,  being attached to therapy and at least one mental health professional,   being hopeful that current treatment direction will be effective,  taking steps to engage in treatment,   a demonstrated ability to reach out when in crisis,.

Medical Decision Making:

• Number and complexity of problems addressed: Moderate- 1 or more chronic illnesses w/exacerbation, progression or side effects
• Risk of complications, morbidity and mortality from Management including testing or treatment: Moderate risk- prescription drug management

Amount and Complexity of Data:

Moderate (reviewing or ordering of at least 3 of- tests/external notes/independent historians OR independently interpreting of a test performed by another professional OR Discussed with other professional)

1 Test(s) reviewed:

Category 3: Discussion of management or test interpretation with an external physician/other qualified health professional aside from supervisor or supervisee/appropriate source:

E/M Code: 99214****

Total Face to Face Time: 30 minutes / Time Spent Not Face to Face (Same Day, Describe): 5 minutes documenting

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PLAN:

Treatment:

• Continue current medication regimen at current dosages.
• Consider in future: Sleep medication if insomnia persists

**Studies/workup:**No labs or other studies indicated at this time

Referrals/External Care: No referrals indicated at this time.

Collateral:obtain collateral as needed

Safety:

There was no indication of currently increased or imminent danger to self or others based on today's exam; outpatient care with close monitoring is appropriate. Modifiable risk factors are being addressed. Safety plan is in place.

Patient/Family aware of how to reach me/covering clinician and members of treatment team in case of emergency (cell) and that email is for non-urgent logistical matters only such as scheduling. Also aware that text messages in the middle of the night are unlikely to be heard so if no response to a text and situation is urgent, calling is most reliable way to reach me. Advised to call 911 or go to the nearest emergency room should any acute safety concerns arise while awaiting a call back.Patient is aware of the 988 Crisis Line as well if needing additional support.

Return to Clinic: 1 month or sooner as needed.

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Benefits of Using a Progress Note Template

• Time-Saving: Having a set structure in place allows for quicker note-taking, reducing the time spent on paperwork.

• Consistency: A template ensures all psychiatrists in a practice maintain similar, comprehensive records.

• Enhanced Communication: Clear, organized notes improve communication among healthcare professionals, ensuring everyone is on the same page regarding a patient's care.

• Improved Patient Care: Detailed, organized notes allow for better assessment and understanding of a patient's needs, leading to more effective treatment strategies.

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How Osmind makes writing a psychiatry progress note easier in your EHR

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Osmind simplifies the process of writing psychiatry progress notes with over 60 templates tailored to for mental health clinicians.  Each template can be customized to fit individual needs, and new ones are continuously added to the library.

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The best part? These templates aren't confined to the Osmind platform. They can be utilized outside of Osmind, allowing you to streamline your documentation process wherever you type. This ensures consistency and accuracy in your notes, giving you peace of mind.

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Ready to embrace the future of mental health? Discover how Osmind's Psychiatry EHR can modernize your practice. Connect with us, and we'll be more than happy to answer your questions and show you how you can save hours off from burdensome admin tasks.