Psychiatric documentation carries unique weight. Notes inform treatment continuity, support prescribing decisions, and may be reviewed in legal or disability contexts. Accuracy, appropriate detail, and careful handling of sensitive information are essential. These templates give you a consistent structure to build on.
Disclaimer: This template is for documentation structure only. Practices should adapt it to their clinical, legal, and organizational requirements. Mental health documentation may be subject to additional privacy protections and regulatory requirements beyond standard medical records.
Initial psychiatric evaluation template
SUBJECTIVE
Visit type: Initial psychiatric evaluation
Referral source: [Self, PCP, court, other provider]
Chief complaint: [Patient's stated reason for seeking care, in their words]
History of present illness:
- Current symptoms: [Description, onset, duration, severity, trajectory]
- Precipitating factors: [Recent stressors, life changes, triggers]
- Functional impact: [Work, relationships, daily activities, self-care]
- Current coping strategies:
- Prior treatment for this concern: [What has been tried, what helped, what did not]
Psychiatric history:
- Prior diagnoses:
- Previous psychiatric hospitalizations: [Dates, facilities, reasons]
- Previous medications tried: [Medication, dose, duration, response, reason discontinued]
- History of psychotherapy: [Type, duration, response]
Substance use history:
- Alcohol: [Frequency, quantity, last use]
- Cannabis: [Frequency, last use]
- Other substances: [Specify]
- Tobacco/nicotine: [Status]
- History of withdrawal or treatment:
Safety assessment:
- Suicidal ideation: [Current SI — passive/active, frequency, intent, plan, means]
- Homicidal ideation: [Current HI — presence, target, intent, plan]
- Self-harm history: [Method, frequency, most recent]
- Violence history:
- Protective factors: [Reasons for living, social support, children, treatment engagement]
- Risk level: [Low / Moderate / High — with supporting rationale]
Medical history: [Active medical conditions relevant to psychiatric care]
Medications: [All current medications with doses]
Allergies: [List with reaction type]
Family psychiatric history: [Psychiatric diagnoses in first-degree relatives, suicide history]
Social history:
- Living situation:
- Employment/education:
- Relationships/support system:
- Legal involvement:
- Trauma history: [Screen — detail per clinical judgment and patient comfort]
Developmental history: [If relevant — early milestones, learning difficulties, ASD screening]
OBJECTIVE
Appearance: [Grooming, hygiene, dress, body habitus, apparent age vs. stated age]
Behavior: [Psychomotor activity, eye contact, cooperation, agitation, restlessness]
Speech: [Rate, rhythm, volume, tone, latency, spontaneity]
Mood: [Patient's own words — e.g., "anxious," "fine," "empty"]
Affect: [Observed — range, congruence with mood, quality: flat, blunted, labile, bright]
Thought process: [Linear, circumstantial, tangential, loose associations, flight of ideas]
Thought content:
- Suicidal ideation: [Restate current status]
- Homicidal ideation: [Restate current status]
- Delusions: [Presence, type]
- Obsessions/compulsions: [If relevant]
- Phobias: [If relevant]
Perceptions: [Hallucinations — auditory, visual, tactile; illusions]
Cognition:
- Orientation: [Person, place, time, situation]
- Attention/concentration: [Observed or tested]
- Memory: [Immediate, recent, remote — if formally assessed]
Insight: [Awareness of illness and need for treatment]
Judgment: [Decision-making capacity based on history and presentation]
ASSESSMENT
1. [Primary diagnosis] — [DSM-5 criteria met, supporting evidence]
2. [Secondary diagnosis if applicable]
3. [Rule-out diagnoses] — [What additional information is needed]
Risk assessment summary: [Risk level with rationale, static and dynamic factors]
PLAN
1. [Diagnosis #1]:
- Medication: [Medication, dose, titration schedule, target symptoms]
- Psychotherapy: [Type recommended, frequency, referral if applicable]
- Lab work: [Baseline labs — CBC, CMP, TSH, lipids, UDS, etc.]
2. Safety plan:
- [Interventions based on risk level — e.g., safety planning, means restriction counseling, crisis resources provided]
- Crisis contacts provided: [988 Lifeline, local crisis line, ER instructions]
3. Referrals: [Therapy, support groups, social services, PCP coordination]
Follow-up: [Timing — e.g., 2 weeks for medication follow-up]
Medication management visit template
SUBJECTIVE
Visit type: Medication management follow-up
Interval history: [Symptom changes since last visit, life events, stressors]
Medication response:
- Current medications: [List with doses]
- Effectiveness: [Symptom improvement — better, same, worse, with specifics]
- Side effects: [New or ongoing — type, severity, impact on adherence]
- Adherence: [Taking as prescribed? Missed doses? Barriers?]
Substance use: [Any changes since last visit]
Safety screen:
- Suicidal ideation: [Current status]
- Self-harm: [Current status]
Functional status: [Work, relationships, sleep, appetite, energy, concentration]
OBJECTIVE
Appearance/behavior: [Brief — notable changes from baseline]
Mood: [Patient-reported]
Affect: [Observed]
Thought process: [Linear vs. disorganized]
Thought content: [SI/HI status, any delusions or obsessions]
Cognition: [Gross assessment — alert, oriented, attentive]
Insight/judgment: [Current assessment]
Relevant labs: [If applicable — e.g., lithium level, metabolic panel, A1c]
ASSESSMENT
1. [Diagnosis] — [Treatment response: responding / partial response / not responding]
- Current regimen: [Summary]
- Risk level: [Update from last visit]
PLAN
1. Medication changes:
- [Continue / adjust / discontinue / add — with rationale]
- [New medication: dose, titration, target symptoms, expected timeline]
- Side effect management: [Plan if applicable]
2. Safety: [Update to safety plan if indicated]
3. Labs ordered: [If monitoring required]
Follow-up: [Timing]
Progress note template (therapy or combined visit)
SUBJECTIVE
Visit type: Progress note — [Therapy / Combined therapy + medication management]
Interval history: [Key events, stressors, mood changes since last session]
Patient-reported progress: [Toward treatment goals — in patient's words when possible]
Current symptoms: [Brief symptom inventory — mood, anxiety, sleep, appetite, concentration]
Safety screen: [SI/HI/self-harm — current status]
OBJECTIVE
Presentation: [Appearance, behavior, affect — brief]
Mental status: [Significant findings or "MSE stable from prior visit" if unchanged]
Therapeutic intervention: [Type of therapy used — e.g., CBT, motivational interviewing]
Patient engagement: [Participation, homework completion, receptivity]
ASSESSMENT
1. [Diagnosis] — [Progressing toward goals / Plateau / Regression]
- Treatment goals addressed this session: [List]
- Risk level: [Update]
PLAN
1. Therapeutic plan: [Next session focus, homework assigned, skills to practice]
2. Medication: [Changes if combined visit, otherwise "no changes"]
3. Coordination: [Communication with PCP, other providers, or family if applicable]
Follow-up: [Next appointment date/frequency]
Documentation considerations for psychiatry
Privacy and record access
Mental health records may have additional privacy protections beyond standard medical records, depending on your jurisdiction and care setting. Psychotherapy notes — defined as notes that go beyond what is needed for treatment, payment, or healthcare operations — may qualify for heightened protection under HIPAA. Understand your organization's policy for what goes in the medical record versus a separate psychotherapy note file.
Risk documentation
Document safety assessments at every visit, even when the patient denies current ideation. This creates a longitudinal record that supports clinical decision-making and provides legal protection. Use a structured approach — ideation, intent, plan, means, protective factors, and risk level determination.
Sensitive disclosures
Patients may disclose trauma, abuse, legal issues, or substance use. Document what is clinically relevant to treatment. Avoid unnecessarily detailed accounts of trauma content in the medical record when a summary serves the clinical purpose. Note mandatory reporting obligations when applicable.
Clinician review is essential
Given the sensitivity and legal implications of psychiatric records, every AI-drafted note should be reviewed carefully. Dictum generates a starting point from the encounter — the clinician ensures the tone, detail level, and content are appropriate before signing.
Related resources
Start with the general SOAP note template for the foundational format. Learn how Dictum supports psychiatry-specific documentation with mental status exam structure and treatment plan formatting. Set up AI-generated SOAP notes that include MSE and safety assessment sections by default.
Frequently asked questions
What is included in a psychiatric mental status exam? A mental status exam (MSE) documents appearance, behavior, speech, mood (patient-reported), affect (observed), thought process, thought content, perceptions, cognition, insight, and judgment. It is recorded in the Objective section of a psychiatry SOAP note.
How detailed should a psychiatry SOAP note be? Detail depends on the visit type. Initial evaluations require comprehensive history and MSE. Medication management visits focus on symptom changes, side effects, and treatment response. All notes should include enough detail to support clinical decision-making and continuity of care.
How do I document suicidal ideation safely? Document the presence or absence of suicidal ideation, intent, plan, means, and protective factors. Use a structured risk assessment framework your organization endorses. Record the risk level determination and the safety plan or interventions in the Plan section.
Should I document therapy content in a SOAP note? Psychotherapy notes that go beyond what is needed for treatment, payment, or operations may qualify for additional protections under regulations like HIPAA. Many organizations keep detailed therapy process notes separate from the medical record. Follow your organization's policy.
Can AI tools handle sensitive psychiatric documentation? Dictum can draft psychiatric SOAP notes from encounters or dictation. Given the sensitive nature of mental health records, clinician review is especially important. Dictum is designed with HIPAA compliance in mind, and every note must be reviewed and approved by the provider.
How do I document involuntary holds or emergency evaluations? Involuntary hold documentation requirements vary by jurisdiction. At minimum, document the legal basis, clinical criteria met, the patient's presentation, and the evaluating clinician's assessment. Follow your facility's specific procedures and legal requirements.
Documentation that respects the complexity of psychiatric care. Try Dictum free — AI-drafted notes with mental status exam structure built in, always under your review.