How to Write Psychiatry Notes with Examples and Templates

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.

1. 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.
2. 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.

There are two common styles for writing these notes: narrative and bulleted. Each style has its own advantages and uses depending on the context and the clinician’s preference.

• Narrative Notes: Narrative notes are less structured and more free-form compared to the other styles. They provide a detailed account of the patient’s session, often in a storytelling format. This style allows for greater flexibility but requires more time to write and review.
• Bulleted Style: The bulleted style uses concise bullet points to list key information. This style is straightforward and focuses on essential details, making it quicker to write and read.

Psychiatric notes are vital for several reasons:

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

In your psychiatry notes, include the following main points:

• Patient Information: Name, date of birth, date of visit, clinician’s name.
• Chief Complaint: Main reason for the visit.
• History: Summary of present illness, past psychiatric history, medical history, family history, social history, and current medications.
• Subjective Information: Patient’s reported symptoms and experiences.
• Objective Information: Mental status examination findings and any relevant physical examination results.
• Assessment: Diagnostic impressions, clinical impressions, and risk assessment.
• Plan: Treatment plan, follow-up schedule, referrals, patient education, and treatment goals.
• Progress: Notes on the patient’s progress and response to treatment since the last visit, including compliance with the treatment plan.

When writing psychiatric notes, consider these tips to ensure clarity, privacy, and comprehensive documentation:

• 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.

Using a progress note template in psychiatry offers several key benefits that enhance clinical practice and patient care:

• Consistency and Standardization: Ensures all necessary information is consistently documented, maintaining uniformity across patient records which is crucial for individual care and clinical audits.
• Efficiency and Time-Saving: Streamlines the note-taking process with predefined sections, reducing time spent on documentation and allowing clinicians to focus more on patient care.
• Improved Quality of Care: Facilitates comprehensive documentation, ensuring no critical information is overlooked, supporting continuity of care, accurate treatment planning, and effective communication among healthcare providers.

How TextExpander Can Help

TextExpander can greatly enhance the efficiency and accuracy of writing psychiatric notes by:

• Standardizing Templates: Create and use standardized templates to ensure all necessary information is consistently documented, improving both efficiency and consistency.
• Inserting Common Phrases: Quickly insert frequently used phrases, medical terms, and diagnostic criteria, saving time and reducing the risk of errors.
• Customizing Shortcuts: Use custom shortcuts for patient-specific information, allowing for quick and accurate insertion of details unique to each patient.

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

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.