How to Write Psychiatry Notes with Examples and Templates

Updated: November 20, 2023

Psychiatric notes are crucial in the management of a patient's mental health care. They not only serve as a record of past interventions, symptoms, and responses but also guide future treatment plans.

This article will delve into what psychiatric notes are, their significance, tips for writing them effectively, and provide templates and examples as a guide to their practical use.

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What are Psychiatric Notes?

Psychiatric notes are written documents that provide a formal account of a patient’s mental health treatment. These notes are typically entered into the patient’s record and may include observations, subjective and objective data, treatment plans, and progress updates.

General

A general psychiatric note may include basic information such as the date of the visit, patient identifiers, the presenting problem, history of the current illness, mental status examination results, diagnoses, and treatment plans.

SOAP Note

A SOAP note is a structured method of documentation that consists of four sections: Subjective, Objective, Assessment, and Plan. This format ensures that the note is clear, systematic, and focuses on specific information regarding the patient’s care and status.

Importance of Psychiatric Notes?

Psychiatric notes are vital for several reasons:

  • Continuity of Care: They ensure that any healthcare professional can pick up a patient’s file and understand the treatment history and future plans.
  • Legal Documentation: Notes serve as a legal record of the care provided and can be essential in the case of litigation.
  • Communication: They facilitate communication among multidisciplinary teams who may be involved in a patient’s care.
    Billing and
  • Reimbursement: Accurate and thorough notes can support billing claims for insurance purposes.

Tips for Writing Psychiatric Notes

  • Be Concise: Write clearly and concisely, avoiding unnecessary jargon.
  • Maintain Patient Privacy: Use identifiers judiciously and ensure that the notes respect patient confidentiality.
  • Use Standardized Tools: Whenever possible, use validated tools for symptom assessment.
  • Include All Relevant Information: Document all medications, dosages, therapeutic interventions, and patient responses.
  • Review and Update Regularly: Notes should be reviewed and updated to reflect changes in the treatment plan or the patient’s status.

Psychiatric Note Templates

Templates can standardize the documentation process, ensuring that all necessary information is included and presented in an organized manner.

General Psychiatric Note Template Copy Snippet Copied!

Patient Information
– Patient Name: [Patient Full Name]
– Date of Birth: [DOB]
– Date of Visit: [Date]
– Appointment Type: [New Consult/Follow-Up]
– Patient ID: [Unique Identifier]

Chief Complaint
– Main Issue(s): [Brief statement of the primary concern or reason for the visit]

History of Present Illness (HPI)
– Description of Symptoms: [Detailed description of symptoms and impact on patient]
– Onset: [When the symptoms started]
– Duration: [How long the symptoms have been occurring]
– Severity: [Scale or description of severity]
– Context: [Circumstances/setting in which symptoms occur]
– Modifying Factors: [Anything that worsens/improves symptoms]
– Associated Signs and Symptoms: [Any other symptoms noted]

Past Psychiatric History
– Previous Diagnoses: [List any past psychiatric diagnoses]
– Hospitalizations: [History of any psychiatric hospitalizations]
– Treatments and Responses: [Prior psychiatric medications and therapies, and responses to them]

Substance Use History
– Alcohol: [Usage and frequency]
– Drugs: [Type, usage, and frequency]

Family Psychiatric History
– Family Disorders: [Any psychiatric disorders in the family]
– Family Dynamics: [Brief description of family structure and relationships]

Social History
– Living Situation: [With whom the patient lives and the nature of the home environment]
– Occupational History: [Current employment status and job, or past employment if relevant]
– Educational Background: [Highest level of education achieved]
– Legal Issues: [Any relevant legal issues or history]
– Support System: [Description of support network]

Mental Status Examination (MSE)
– Appearance: [Observations of patient’s physical appearance and behavior]
– Attitude: [Cooperative, hostile, etc.]
– Behavior: [Any unusual movements, activity level]
– Speech: [Rate, volume, articulation]
– Mood and Affect: [Patient’s reported mood and observed affect]
– Thought Process: [Rate, continuity, coherence of thought]
– Thought Content: [Presence of delusions, hallucinations, etc.]
– Cognition: [Orientation, attention, memory, general knowledge, abstract thinking]
– Insight: [Understanding of one’s own condition]
– Judgment: [Ability to make reasoned decisions]

Assessment
– Diagnostic Impression: [Clinical diagnoses based on DSM criteria]
– Risk Assessment: [Risk of harm to self or others]

Plan
– Medication: [Any changes to medication, dosages, or regimen]
– Psychotherapy: [Type and frequency of therapy planned]
– Orders and Referrals: [Any orders for labs, imaging, or referrals to other providers]
– Follow-Up: [Timing and focus for the next appointment]

SOAP Note Template for Psychiatry Copy Snippet Copied!

Subjective
– Chief Complaint: [Patient’s statement about their main issue]
– History of Present Illness (HPI): [Description of current symptoms, onset, duration, and severity]
– Review of Systems (Psych): [Patient’s description of psychiatric symptoms]
– Patient’s Perception: [Patient’s understanding and beliefs regarding their illness]

Objective
– Vital Signs: [BP, HR, Temperature, etc., if relevant]
– Mental Status Examination (MSE): [Objective findings during the visit]
– Appearance
– Behavior
– Speech
– Mood and Affect
– Thought Process/Content
– Cognition
– Insight/Judgment
– Physical Examination: [Relevant findings, if any]

Assessment
– Diagnosis: [Diagnosis or differential diagnoses, with DSM codes if applicable]
– Progress: [Comparison with previous status or baseline]
– Risk Factors: [Any risk factors for violence, self-harm, or non-compliance]

Plan
– Medications: [List changes, additions, or continuations]
– Psychotherapy: [Type, focus, frequency of sessions]
– Education: [Information provided to the patient about their condition]
– Follow-Up: [Timing and specific goals for next visit]
– Referrals: [Referrals to other services or specialists, if needed]
– Safety Planning: [Any arrangements made considering risk assessment]

Examples of Psychiatric Notes

These examples align with the templates provided and can be used as a guide in the documentation of psychiatric care.

General Psychiatric Note Example

Patient Information
– Patient Name: John Doe
– Date of Birth: 01/01/1980
– Date of Visit: 11/06/2023
– Appointment Type: Follow-Up
– Patient ID: JD-1006

Chief Complaint
– Main Issue(s): “I’m constantly worried about everything, even when I know there’s no need.”

History of Present Illness (HPI)
– Description of Symptoms: Persistent, excessive worry most days, difficulty controlling the worry.
– Onset: Approximately 6 months ago.
– Duration: Daily, persistent worry since onset.
– Severity: Patient rates anxiety 7/10.
– Context: Mostly in social situations and at work.
– Modifying Factors: Exercise appears to mildly improve symptoms.
– Associated Signs and Symptoms: Insomnia, fatigue, irritability.

Past Psychiatric History
– Previous Diagnoses: None reported.
– Hospitalizations: None reported.
– Treatments and Responses: No prior treatments reported.

Substance Use History
– Alcohol: Denies use.
– Drugs: Denies use.

Family Psychiatric History
– Family Disorders: Mother has a history of depression.
– Family Dynamics: Single, lives alone.

Social History
– Living Situation: Lives alone in a one-bedroom apartment.
– Occupational History: Employed as a software developer.
– Educational Background: Bachelor’s degree in Computer Science.
– Legal Issues: None reported.
– Support System: Has a few close friends, estranged from family.

Mental Status Examination (MSE)
– Appearance: Well-groomed, appears stated age.
– Attitude: Cooperative.
– Behavior: Mildly restless.
– Speech: Clear and coherent.
– Mood and Affect: Anxious mood, affect somewhat constricted.
– Thought Process: Goal-directed.
– Thought Content: No delusions or hallucinations reported or observed.
– Cognition: Oriented to time, place, and person. Intact attention and memory.
– Insight: Fair.
– Judgment: Good.

Assessment
– Diagnostic Impression: Generalized Anxiety Disorder (GAD), moderate.
– Risk Assessment: No suicidal or homicidal ideation reported or suspected.

Plan
– Medication: Recommend initiating an SSRI, sertraline 50 mg daily.
– Psychotherapy: Weekly cognitive-behavioral therapy (CBT) sessions.
– Orders and Referrals: Routine blood work to rule out any metabolic causes of anxiety.
– Follow-Up: Scheduled for 4 weeks to reassess medication efficacy and symptomatology.

SOAP Note Example for Psychiatry

Subjective
– Chief Complaint: “I’ve been having panic attacks out of nowhere, and it’s scary.”
– History of Present Illness (HPI): Frequent episodes of intense fear accompanied by physical symptoms such as palpitations and shortness of breath. Episodes last about 10-15 minutes.
– Review of Systems (Psych): Patient reports intermittent periods of depression but no other symptoms.
– Patient’s Perception: Feels overwhelmed and worried about the possibility of future attacks.

Objective
– Vital Signs: BP 140/90, HR 110, Temperature 98.6°F.
– Mental Status Examination (MSE):
– Appearance: Anxious, fidgeting with clothing.
– Behavior: Restless.
– Speech: Rapid, pressured.
– Mood and Affect: Reports mood as “terrified,” affect is anxious.
– Thought Process/Content: No evidence of delusions or hallucinations. Fears centered around health concerns.
– Cognition: Alert and oriented to time, place, and person. Concentration intact.
– Insight/Judgment: Limited insight into anxiety triggers, judgment appears intact.
– Physical Examination: Chest auscultation normal, no signs of distress.

Assessment
– Diagnosis: Panic Disorder without Agoraphobia (F41.0).
– Progress: This is a new diagnosis.
– Risk Factors: Elevated blood pressure and heart rate during the attack.

Plan
– Medications: Initiate an SSRI, escitalopram 10 mg once daily.
– Psychotherapy: Begin cognitive-behavioral therapy focusing on panic management.
– Education: Provided patient education on panic disorder and the role of SSRIs.
– Follow-up: In two weeks to monitor response to medication and review CBT techniques.
– Referrals: None at this time.
– Safety Planning: Advised patient to avoid caffeine and to use deep breathing techniques during panic onset.

Proper psychiatric documentation can enhance the quality of care and support the therapeutic goals set forth for every individual patient. By utilizing formats such as general notes or SOAP notes, mental health professionals can ensure comprehensive care and communication.

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Patient Information <br>- Patient Name: [Patient Full Name] <br>- Date of Birth: [DOB] <br>- Date of Visit: [Date] <br>- Appointment Type: [New Consult/Follow-Up] <br>- Patient ID: [Unique Identifier] <br> <br>Chief Complaint <br>- Main Issue(s): [Brief statement of the primary concern or reason for the visit] <br> <br>History of Present Illness (HPI) <br>- Description of Symptoms: [Detailed description of symptoms and impact on patient] <br>- Onset: [When the symptoms started] <br>- Duration: [How long the symptoms have been occurring] <br>- Severity: [Scale or description of severity] <br>- Context: [Circumstances/setting in which symptoms occur] <br>- Modifying Factors: [Anything that worsens/improves symptoms] <br>- Associated Signs and Symptoms: [Any other symptoms noted] <br> <br>Past Psychiatric History <br>- Previous Diagnoses: [List any past psychiatric diagnoses] <br>- Hospitalizations: [History of any psychiatric hospitalizations] <br>- Treatments and Responses: [Prior psychiatric medications and therapies, and responses to them] <br> <br>Substance Use History <br>- Alcohol: [Usage and frequency] <br>- Drugs: [Type, usage, and frequency] <br> <br>Family Psychiatric History <br>- Family Disorders: [Any psychiatric disorders in the family] <br>- Family Dynamics: [Brief description of family structure and relationships] <br> <br>Social History <br>- Living Situation: [With whom the patient lives and the nature of the home environment] <br>- Occupational History: [Current employment status and job, or past employment if relevant] <br>- Educational Background: [Highest level of education achieved] <br>- Legal Issues: [Any relevant legal issues or history] <br>- Support System: [Description of support network] <br> <br>Mental Status Examination (MSE) <br>- Appearance: [Observations of patient’s physical appearance and behavior] <br>- Attitude: [Cooperative, hostile, etc.] <br>- Behavior: [Any unusual movements, activity level] <br>- Speech: [Rate, volume, articulation] <br>- Mood and Affect: [Patient’s reported mood and observed affect] <br>- Thought Process: [Rate, continuity, coherence of thought] <br>- Thought Content: [Presence of delusions, hallucinations, etc.] <br>- Cognition: [Orientation, attention, memory, general knowledge, abstract thinking] <br>- Insight: [Understanding of one’s own condition] <br>- Judgment: [Ability to make reasoned decisions] <br> <br>Assessment <br>- Diagnostic Impression: [Clinical diagnoses based on DSM criteria] <br>- Risk Assessment: [Risk of harm to self or others] <br> <br>Plan <br>- Medication: [Any changes to medication, dosages, or regimen] <br>- Psychotherapy: [Type and frequency of therapy planned] <br>- Orders and Referrals: [Any orders for labs, imaging, or referrals to other providers] <br>- Follow-Up: [Timing and focus for the next appointment]
Subjective <br>- Chief Complaint: [Patient’s statement about their main issue] <br>- History of Present Illness (HPI): [Description of current symptoms, onset, duration, and severity] <br>- Review of Systems (Psych): [Patient’s description of psychiatric symptoms] <br>- Patient’s Perception: [Patient's understanding and beliefs regarding their illness] <br> <br>Objective <br>- Vital Signs: [BP, HR, Temperature, etc., if relevant] <br>- Mental Status Examination (MSE): [Objective findings during the visit] <br> - Appearance <br> - Behavior <br> - Speech <br> - Mood and Affect <br> - Thought Process/Content <br> - Cognition <br> - Insight/Judgment <br>- Physical Examination: [Relevant findings, if any] <br> <br>Assessment <br>- Diagnosis: [Diagnosis or differential diagnoses, with DSM codes if applicable] <br>- Progress: [Comparison with previous status or baseline] <br>- Risk Factors: [Any risk factors for violence, self-harm, or non-compliance] <br> <br>Plan <br>- Medications: [List changes, additions, or continuations] <br>- Psychotherapy: [Type, focus, frequency of sessions] <br>- Education: [Information provided to the patient about their condition] <br>- Follow-Up: [Timing and specific goals for next visit] <br>- Referrals: [Referrals to other services or specialists, if needed] <br>- Safety Planning: [Any arrangements made considering risk assessment]
Patient Information <br>- Patient Name: John Doe <br>- Date of Birth: 01/01/1980 <br>- Date of Visit: 11/06/2023 <br>- Appointment Type: Follow-Up <br>- Patient ID: JD-1006 <br> <br>Chief Complaint <br>- Main Issue(s): "I'm constantly worried about everything, even when I know there's no need." <br> <br>History of Present Illness (HPI) <br>- Description of Symptoms: Persistent, excessive worry most days, difficulty controlling the worry. <br>- Onset: Approximately 6 months ago. <br>- Duration: Daily, persistent worry since onset. <br>- Severity: Patient rates anxiety 7/10. <br>- Context: Mostly in social situations and at work. <br>- Modifying Factors: Exercise appears to mildly improve symptoms. <br>- Associated Signs and Symptoms: Insomnia, fatigue, irritability. <br> <br>Past Psychiatric History <br>- Previous Diagnoses: None reported. <br>- Hospitalizations: None reported. <br>- Treatments and Responses: No prior treatments reported. <br> <br>Substance Use History <br>- Alcohol: Denies use. <br>- Drugs: Denies use. <br> <br>Family Psychiatric History <br>- Family Disorders: Mother has a history of depression. <br>- Family Dynamics: Single, lives alone. <br> <br>Social History <br>- Living Situation: Lives alone in a one-bedroom apartment. <br>- Occupational History: Employed as a software developer. <br>- Educational Background: Bachelor's degree in Computer Science. <br>- Legal Issues: None reported. <br>- Support System: Has a few close friends, estranged from family. <br> <br>Mental Status Examination (MSE) <br>- Appearance: Well-groomed, appears stated age. <br>- Attitude: Cooperative. <br>- Behavior: Mildly restless. <br>- Speech: Clear and coherent. <br>- Mood and Affect: Anxious mood, affect somewhat constricted. <br>- Thought Process: Goal-directed. <br>- Thought Content: No delusions or hallucinations reported or observed. <br>- Cognition: Oriented to time, place, and person. Intact attention and memory. <br>- Insight: Fair. <br>- Judgment: Good. <br> <br>Assessment <br>- Diagnostic Impression: Generalized Anxiety Disorder (GAD), moderate. <br>- Risk Assessment: No suicidal or homicidal ideation reported or suspected. <br> <br>Plan <br>- Medication: Recommend initiating an SSRI, sertraline 50 mg daily. <br>- Psychotherapy: Weekly cognitive-behavioral therapy (CBT) sessions. <br>- Orders and Referrals: Routine blood work to rule out any metabolic causes of anxiety. <br>- Follow-Up: Scheduled for 4 weeks to reassess medication efficacy and symptomatology.
Subjective <br>- Chief Complaint: "I've been having panic attacks out of nowhere, and it's scary." <br>- History of Present Illness (HPI): Frequent episodes of intense fear accompanied by physical symptoms such as palpitations and shortness of breath. Episodes last about 10-15 minutes. <br>- Review of Systems (Psych): Patient reports intermittent periods of depression but no other symptoms. <br>- Patient’s Perception: Feels overwhelmed and worried about the possibility of future attacks. <br> <br>Objective <br>- Vital Signs: BP 140/90, HR 110, Temperature 98.6°F. <br>- Mental Status Examination (MSE): <br> - Appearance: Anxious, fidgeting with clothing. <br> - Behavior: Restless. <br> - Speech: Rapid, pressured. <br> - Mood and Affect: Reports mood as "terrified," affect is anxious. <br> - Thought Process/Content: No evidence of delusions or hallucinations. Fears centered around health concerns. <br> - Cognition: Alert and oriented to time, place, and person. Concentration intact. <br> - Insight/Judgment: Limited insight into anxiety triggers, judgment appears intact. <br>- Physical Examination: Chest auscultation normal, no signs of distress. <br> <br>Assessment <br>- Diagnosis: Panic Disorder without Agoraphobia (F41.0). <br>- Progress: This is a new diagnosis. <br>- Risk Factors: Elevated blood pressure and heart rate during the attack. <br> <br>Plan <br>- Medications: Initiate an SSRI, escitalopram 10 mg once daily. <br>- Psychotherapy: Begin cognitive-behavioral therapy focusing on panic management. <br>- Education: Provided patient education on panic disorder and the role of SSRIs. <br>- Follow-up: In two weeks to monitor response to medication and review CBT techniques. <br>- Referrals: None at this time. <br>- Safety Planning: Advised patient to avoid caffeine and to use deep breathing techniques during panic onset.

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