High quality documentation is a vital part of making sure that each visit tells a clear but concise story of what occurred during your patient visit. Documentation is used to track patient progress, prove medical necessity and allow other providers to quickly see what has been done for the patient. High quality documentation allows you to confidently highlight your care decisions should they ever be reviewed or questioned in court. Remember the saying “if you didn’t document it, it didn’t happen”
Examples with rational and best practice recommendations
Chief Complaint:
Example: “I’ve been feeling on edge, angry, tired and irritable lately. It’s causing trouble at work for me”
What to Document: The patient’s main reason for seeking psychiatric, expressed in their own words. Each visit should have a unique chief complaint.
Rationale: This highlights the patient’s main concerns and allows the provider to focus on the patient’s most pressing issue and facilitates shared decision making.
Best Practices:
- Include the patient’s primary reason for the visit in their own words whenever possible.
- Avoid medical jargon; keep it concise and reflective of the patient’s concerns.
- Make sure to address the patient’s main concerns which will allow them to feel heard and a part of the decision making process.
History of Present Illness (HPI):
Example: Mrs. Smith is a 45-year-old female with a history of generalized anxiety disorder (GAD) and insomnia, presenting today for worsening symptoms over the past two weeks. She reports increased worry about her job performance, difficulty concentrating, and trouble falling asleep 4-5 nights per week. She denies changes in appetite or suicidal ideation.
Stressors include deadlines at work and limited social support due to recent relocation. She was started on Lexapro a few months ago by her PCP, but did not like the way it made her feel and reported daily nausea that did not resolve. She stopped using the medication after 1 week.
She has avoided screen time or eating before bed but is still struggling to fall asleep before 2am which has made her late for work several times each week. She was talked to about her tardiness by her manager and is afraid she will receive further disciplinary action.
Her GAD 7 score has increased from 12 to 18 since her manager noted her continual tardiness. Her PHQ 9 score has also increased from 8 to 12 over the past 2 weeks. She is highly motivated to change and recently started seeing a therapist weekly. She is open to trying a new medication to help with her anxiety, mood and sleep issues.
What to Document: Details about the onset, duration, intensity, and progression of symptoms. Include triggers, coping strategies, and associated psychosocial stressors.
Rationale: Provides a nuanced understanding of the current problem, which is critical for formulating a diagnosis and treatment plan. It distinguishes chronic issues from acute exacerbations.
Best Practices:
- Include onset, duration, and severity of symptoms.
- Relate symptoms to psychosocial stressors or triggers.
- Incorporate relevant clinical tools (e.g., GAD-7 score of 18).
Measurement-Informed Care (MIC):
Example:
- GAD-7 Results: Score of 18, indicating severe anxiety.
- PHQ-9 Results: Score of 12, reflecting moderate depressive symptoms.
What to Document: Baseline data from validated tools (e.g., PHQ-9, GAD-7) and patient-reported functional impairments.
Rationale: MIC tools provide objective data to track symptoms over time, ensuring treatment effectiveness and improving clinical decision-making. They also support value-based care models.
Best Practices:
- Track scores over time to objectively measure treatment progress.
- Use MIC tools to facilitate shared decision-making with the patient.
Suicide Risk Assessment:
Example:
- Current Risk: The patient denies suicidal ideation, intent, or plan. Her C-SSRS score is 0/6. She has a supportive friend network and loves her pets. She is currently at low risk for suicide and reports feeling able to reach out for support if she is experiencing worsening depressive sx.
- Protective Factors: Strong work ethic, religious beliefs, and desire to support family, loves her pets
- Risk factors: history of depression, work related stress, bullying
- Warning Signs: Reports passive thoughts of hopelessness when under stress but denies active suicidal thoughts.
- Safety measures: Safety plan created in session with pt and she agrees to post it on her fridge so that it is clearly visible. She has contact information for her therapist as well as support resources such as the crisis text line and 988. She does not have access to firearms and reports that her environment is free from sharp instruments.
What to Document: Current suicidal ideation, past attempts, protective factors, and safety measures.
Rationale: Suicide prevention is a critical component of psychiatric care. Thorough documentation is vital and can show that protective measures and best practices were used to try and minimize risk. Legally, quality documentation of a suicide risk assessment is a core component of a high quality chart.
Best Practices:
- Use direct questions to assess ideation, intent, and planning.
- Document protective factors, such as family or goals.
- Include clinical judgment about overall risk level.
- Complete a safety plan when indicated and make sure the patient is given a copy
- Make sure to review the suicide risk assessment during each patient session and monitor for changes
Trauma/Violence Risk Assessment:
Example:
- Have you been troubled or injured by any kind of abuse or violence?: Pt reports a prior relationship in which she was being physically abused by her partner. She was able to leave that relationship 5 years ago
- Do you have anyone you can turn to or rely on now to protect you from possible further injury? Pt reports that her current partner is supportive and non abusive. She feels safe in the relationship and has no further contact with her ex.
- Have you ever intentionally threatened or caused bodily harm to someone in the past? Pt denies any history of physical violence towards another person. Denies any current thoughts of wanting to harm someone else.
What to Document: Any past history of trauma/abuse should be noted as well as any thoughts of wanting to hurt anyone else.
Rationale: A trauma and violence risk assessment is essential to identify the psychological and functional impact of trauma, as well as potential risks of harm to self or others. This process ensures the development of an informed, safety-oriented treatment plan that addresses the patient’s needs while mitigating immediate and long-term risks
Best Practices:
- Create a Safe and Supportive Environment: Use trauma-informed language and establish trust to encourage honest disclosure while avoiding re-traumatization.
- Gather a Comprehensive History: Explore past and recent traumatic experiences, violent behaviors, and contributing factors, including substance use and stressors.
- Assess Risk and Impact: Evaluate the psychological and functional effects of trauma and identify risk factors, protective factors, and warning signs of violence or harm.
- Screen for Current Intentions: Ask directly about thoughts or plans related to self-harm, harming others, or exposure to violence, and assess access to weapons or other means.
- Document and Plan: Clearly document findings, collaborate on a safety plan if needed, and use validated tools (eg. PCL-5, ACE, TSQ) to inform treatment and interventions.
Substance History:
Example:
- Tobacco: started smoking age 14, 20 pack year smoking history. Quit smoking 2 years ago
- Alcohol: drinks 1-2 mixed drinks each evening, 7 days a week
- Cannabis: reports occasional use of THC gummy at night to help with sleep
- Cocaine: denies, never tried
- Heroin: denies, never tried
- Opiates: reports trying fentanyl one time in college. Denies any current use
- Misuse of prescription medication: states that she bought Adderall in college a few times. Denies any active prescription medication use/misuse
What to document: Include current and previous use of illegal and legal substances. Make sure to include misuse/abuse of prescription medications. Specify if they are currently using that substance. Don't forget about over the counter substances such as Kratum.
Rationale: Obtaining a comprehensive substance use history will allow you to implement harm reduction strategies, assess for contributing factors to mental health conditions (ie. using cocaine and reporting anxiety) and will allow you to ensure that there are no contraindications to prescribing various mental health medications.
Best Practices:
- Make sure to ask specifically about how the substance is used (ie. vaping, smoking, chewing, injecting) when applicable.
- For any positive findings, follow up with the appropriate screening tool implementation (ie. CAGE, Audit-C)
- Maintain a non-judgemental, helpful attitude and use motivational interviewing to explore substance use and readiness for change.
- Even if the patient is not ready for change, continue to reassess at follow up visits and provide encouragement and support.
Allergies/PCP Information/Vital Signs:
Example:
- Medication allergy: Allergy to PCN, caused a rash as an infant
- Food allergy: Allergic to eggs and peanuts, carries an epi pen
- Environmental allergy: Allergic to cats
- PCP: Dr. Susan Smith at Health Care Partners in Pasadena, CA (626)123-4567
- Last physical exam: June 2024
- Last lab work: June 2024, will request records. States most recent TSH was normal.
- Current height: 5’7
- Current weight: 152 lbs
- Most recent blood pressure: 124/68
What to document: Make sure to document any allergies as well as the reaction (if known). Gather information for their PCP (if they have one) as well as most recent BP, physical exam, height and weight as well as note when they last had lab work obtained.
Rationale: Documenting allergies is essential to avoid prescribing medications that could trigger an allergic reaction. Collecting primary care provider information, along with vital signs (height, weight, and blood pressure) and details of the last exam or lab work, enables effective communication and records review, supporting a more comprehensive and informed clinical evaluation.
Best Practices:
- Inquire about medication, food, and environmental allergies, including reactions, and document clearly.
- Obtain accurate contact details for the primary care provider to facilitate collaboration and records requests.
- Ask about the date and results of the last physical exam or lab work for a comprehensive health overview.
- Record height, weight, and blood pressure to assess overall health and ensure safe prescribing practices.
- Address gaps by requesting permission to follow up with the PCP or other providers as needed.
Past and Current Medication History:
Example:
- Topamax 25mg nightly for migraine prevention
- Previously trialed Lexapro 10mg daily (2022) but discontinued after 1 week due to nausea and headaches
- Daily multivitamin, nexplanon (placed 2024), Vit D 2000 units a day
What to document: Current and previous psychiatric and relevant non psychiatric medications (with dates of use and dosages if possible). Current prescription and non prescription medications as well as any OTC supplements.
Rationale: A complete review of the patient’s medication history will explore past medication trials, open dialogue surrounding medication expectations and side effects as well as highlight potential drug interactions.
Best practices:
- Document medication names, dosages, start and stop dates, response and name of prior prescriber whenever possible.
- Evaluate for possible medication drug-drug reactions and include exploration of herbal supplements/CAM treatments.
- Explore any reported allergic reactions/intolerance to better understand the patient’s experience.
Past Medical and Psychiatric History:
Example:
- Medical History: Migraine headaches with aura since age 13. Uses nightly topamax for migraine prevention. Appendectomy age 21. Denies any long term hospitalizations.
-
Psychiatric History: Diagnosed with GAD and MDD at age 30. Participated in therapy for approx 1 yr and then discontinued due to insurance loss. Pt previously tried Lexapro 10 mg as prescribed by her PCP but discontinued due to continued nausea and headaches. Denies any prior mental health hospitalizations.
- History of mania: denies
- History of non suicidal self harming behaviors: cutting episode in 7th grade, none since
- History of auditory or visual hallucinations: denies hearing voices or seeing things that others do not see.
What to Document:
- Medical History: Chronic illnesses, surgeries, and hospitalizations. Include significant medical conditions that could affect mental health or medication management (e.g., thyroid disorders, neurological conditions).
- Psychiatric History: Previous mental health diagnoses, hospitalizations, and therapy experiences. Note any prior psychiatric evaluations,diagnoses, treatments, and their outcomes. Include screening for self harming behaviors, mania and hallucinations.
Rationale: Getting a detailed past medical and psychiatric history helps understand the patient’s current condition and ensure safe, effective treatment. Knowing their past psychiatric history is important to see what diagnoses and treatments have worked or not worked before, helping guide the best plan of care for the patient.
Best Practices:
- Encourage patients to share details about past diagnoses, treatments, and experiences in their own words.
- Inquire about what treatments have been effective or ineffective, including reasons for stopping medications or therapies.
- Prioritize information about chronic illnesses, surgeries, psychiatric diagnoses, hospitalizations, and therapy experiences.
Family Psychiatric and Pertinent Family Medical History:
Example:
- Psychiatric: Mother diagnosed with major depressive disorder; brother with alcohol use disorder.
-
Medical: Father has hypertension and Type 2 diabetes.
- History of sudden cardiac death: Denies
- History of cardiac rhythm irregularities: reports that grandfather had an unknown heart condition and passed at age 86 from a blood clot.
What to Document: Family history of psychiatric and pertinent medical illnesses. (eg. mother with hx of BPAD, father passed from SCD)
Rationale: A family medical and psychiatric history helps identify conditions that may run in the family and affect the patient’s mental health. It provides insight into possible genetic or environmental factors influencing their symptoms and helps guide treatment and preventive care. Checking for heart conditions is especially important when considering stimulant medications, as these can increase heart rate and blood pressure, posing risks for individuals with underlying cardiac issues.
Best Practices:
- Focus on hereditary conditions and their relevance to the patient’s presentation such as bipolar disorder, schizophrenia, ADHD, cardiac anomalies such as WPW or SCD.
Social History
Example:
- Family structure: Lives with supportive parents and has one sibling. Minimal contact with extended family members.
- Education: Bachelor’s degree in business administration.
- Occupation: Works full-time as a marketing manager at a local firm.
- Sexual identifiers or preferences: Transgender woman (male-to-female), identifies as bisexual, and is currently single.
- Cultural considerations: Identifies as atheist and values evidence-based approaches to treatment without a spiritual focus. Prefers providers who are experienced with LGBTQ+ care.
- Military/legal: No history of military service; no current or past legal issues.
What to Document:
Living Situation:
- Where the patient lives, with whom, and stability of housing.
Family and Relationships:
- Dynamics with family members, marital/partner status, quality of support.
Educational/Occupational History:
- Current and past education, employment, work stressors, or academic challenges.
Cultural and Religious Background:
- Beliefs, practices, or identities affecting health and wellness.
Legal Issues:
- Any involvement with the legal system, including custody battles or criminal charges.
Military involvement:
- Document branch of service, duration of service, rank, deployment history, combat exposure, type of discharge, and any service-related physical or mental health concerns (e.g., PTSD, TBI).
Recreational Activities:
- Hobbies or interests that provide fulfillment or are lacking.
Rationale: Obtaining a social history during a psychiatric evaluation provides critical context about the patient’s relationships, environment, and life circumstances that may influence their mental health. It helps identify social determinants of health, support systems, stressors, and protective factors, which are essential for developing a holistic and effective treatment plan.
Best Practices:
- Explore family dynamics, relationships, housing stability, employment, and education.
- Identify financial stress, access to healthcare, and other external factors affecting mental health.
- Understand recent challenges or major life changes impacting the patient.
- Assess the patient’s social connections and availability of support networks.
- Tailor questions and interpretations to the patient’s cultural background and environmental circumstances.
Review of Systems
Example:
- Neurological: reports occasional migraine headaches (1-2 times a year), denies any hx of concussions
- Cardiovascular: denies any chest pain or palpitations, last EKG 2023
- Respiratory: asthma as a child, has a rescue inhaler but has not used to 10 years
- Endocrine: denies any DM dx, reports increase hair loss and always cold
- Gastrointestinal: reports frequent diarrhea, alternating with constipation. Denies nausea or vomiting. Hx of IBS.
- Genitourinary: denies any burning with urination. Last UTI was 5 yrs ago per pt.
- Musculoskeletal: reports chronic low back pain d/t a skiing accident, +bilateral wrist pain d/t CTS
- Sleep: reports snoring with excessive daytime sleepiness.
What to Document:
- Neurological: Note any history of headaches, seizures, dizziness, or traumatic brain injury (TBI) that could impact mental health or medication use.
- Cardiovascular: Document chest pain, palpitations, or a history of hypertension, as these may influence medication safety, especially with stimulants.
- Respiratory: Record issues like shortness of breath or asthma that may signal stress or impact physical well-being.
- Endocrine: Include changes in weight, appetite, or history of thyroid disorders or diabetes, as these can mimic or exacerbate psychiatric symptoms.
- Gastrointestinal: Capture any nausea, abdominal pain, or bowel changes that may relate to stress, medication side effects, or underlying conditions.
- Genitourinary: Note changes in urination or menstrual irregularities that could be linked to hormonal or medication effects.
- Musculoskeletal: Document chronic pain, joint stiffness, or mobility issues, as these can affect mood and functioning.
- Sleep: Assess for insomnia, excessive sleepiness, or poor sleep quality, which are critical for diagnosing and managing mental health conditions.
Rationale: The review of systems during a psychiatric evaluation helps identify physical symptoms or medical conditions that may contribute to or mimic psychiatric symptoms. This information ensures a comprehensive understanding of the patient’s overall health, supports accurate diagnosis, and guides safe and effective treatment planning.
Best Practices:
- Focus on symptoms relevant to mental health, such as sleep disturbances, appetite changes, or chronic pain.
- Identify medical issues (e.g., thyroid disorders or diabetes) that may mimic or exacerbate psychiatric symptoms.
- Pay attention to cardiovascular, neurological, or endocrine conditions that may impact medication choices or safety.
Mental Status Exam (MSE):
Example:
- General: The patient appears well-groomed, dressed appropriately for the weather, and demonstrates good hygiene. Posture is relaxed, and eye contact is consistent.
- Attitude/Behavior: The patient is cooperative, engaged, and attentive during the session. No evidence of hostility or guardedness is noted.
- Motor Activity: No abnormalities observed. Motor activity is within normal limits, with no psychomotor agitation or retardation.
- Speech: Speech is normal in rate, rhythm, tone, and volume. No evidence of pressured or slowed speech.
- Affect: The patient exhibits a full range of affect, appropriate to the content of discussion.
- Mood: The patient reports feeling "calm" and "hopeful."
- Thought Process: The patient demonstrates a logical and goal-directed thought process, with no evidence of flight of ideas or tangential thinking.
- Thought Content: No delusions, hallucinations, or obsessions reported or observed. The patient denies suicidal or homicidal ideation.
- Insight: Insight is fair. The patient acknowledges difficulties and expresses willingness to engage in treatment but has limited understanding of contributing factors.
- Judgment: Judgment appears intact, with the patient demonstrating sound decision-making and understanding of potential consequences.
- Cognition/Memory: The patient is alert and oriented to person, place, time, and situation. Immediate, recent, and remote memory appear intact based on informal assessment.
What to Document: Observations of the patient’s appearance, behavior, mood, affect, thought processes, and cognition.
Rationale: Provides an objective snapshot of the patient’s current mental state, aiding in diagnosis and treatment planning.
Best Practices:
- Include objective observations of mood, thought process, and behavior.
- Avoid assumptions; report only what is observed.
- Use a direct quote of the patient’s mood when possible
Controlled Medication Prescription Checklist/PDMP:
Example:
Medication: Vyvanse 50mg daily
Indication: ADHD, inattentive type
Upon prescribing a stimulant, I attest to have checked and/or completed the following:
1. Personal and family history reviewed, including but not limited to: family history of sudden cardiac death, history of Wolff-Parkinson-White (WPW) syndrome, arrhythmias
2. If history of hypertension, well-controlled
3. Childhood history of ADHD symptoms prior to age 12
4. Two areas of functioning affected by ADHD symptoms
5. Explored the possibility of overlap with other conditions
6. Behavioral interventions discussed
7. Will continue to provide close monitoring with initial follow-up in 30 days
8. Controlled medication contract reviewed and verbal consent was given by the patient
9. Requested records as needed
10. If history of substance use, a plan is in place to monitor closely with random urine drug screening as indicated
11. CURES/PDMP checked and either records were found OR no signs of abuse or diversion were noted
What to Document: Document the name of the medication, the dose and the indication as well as a review of all relevant clinical information needed to safely prescribe the controlled substance.
Rationale: This comprehensive checklist ensures the safe and effective prescribing of controlled medications by addressing key factors that influence patient safety, diagnostic accuracy, and long-term outcomes.
Best practices:
- Review personal and family history to help mitigate risks of cardiac complications
- Confirm ADHD symptoms from childhood and their impact on functioning to ensure diagnostic validity.
- Screen for overlapping conditions, discuss behavioral interventions, and obtain consent to reinforce a holistic and ethical approach to treatment.
- Maintain close monitoring, schedule regular follow-ups, review the controlled medication contract and check the PDMP to ensure ongoing safety and reduce the risk of misuse or diversion. These steps support adherence to best practices in stimulant prescribing.
DSM-5 Diagnosis:
Example:
F41.1 Generalized Anxiety Disorder: Pt reports feelings of overwhelm, trouble staying focused, uneasiness, and difficulty sleeping. She has been experiencing these symptoms for the past 18 months, worse over the past 6 months. Current GAD score of 18/21.
F33.1 Major depressive disorder, recurrent, moderate: Pt reports loss of interest, decreased appetite, crying spells, passive thoughts of not wanting to be alive, difficulty showering and brushing her teeth for the past month. She was dx with MDD in her early 20s. Current PHQ-9 score of 12.
F43.22 Ddx: Adjustment disorder with anxiety: Pt reports recent write up for lateness and reports that her anxiety has heightened since the discussion a few weeks ago. She has been having trouble sleeping due to racing thoughts and replaying the meeting with her manager over and over in her head.
What to Document: Primary and secondary diagnoses based on DSM-5 criteria. Include provisional (differential) diagnoses if necessary.
Rationale: A clear and accurate diagnosis guides the treatment plan and justifies medical necessity for care.
Best Practices:
- Use DSM-5/ICD-10 codes where applicable.
- Ensure diagnosis reflects the symptoms and clinical picture (it must be congruent with the HPI)
- Briefly explain what symptoms/presentation meet the DSM 5 criteria for the diagnosis chosen
- Include a differential diagnosis when applicable
Assessment (Biopsychosocial Approach):
Example:
- Biological: The patient reports no significant side effects from current medications but continues to struggle with insomnia. Her migraine headaches are well managed and no major changes in physical health were reported. Family history is notable for depression and substance use disorders.
- Psychological: The patient’s PHQ-9 score has increased from the previous visit (8 to 12), indicating exacerbation of the pt’s depressive symptoms. Anxiety also remains a concern as reflected in a GAD-7 score of 18/21. The patient verbalized feelings of hopelessness regarding workplace stress but denied suicidal ideation.
- Social: The patient is under significant financial stress due to missing hours at work due to tardiness and expresses difficulty maintaining social relationships. She identifies good support from family but struggles with social withdrawal, which is exacerbating feelings of isolation.
- Clinical Impression: Pt has increased depressive and anxiety symptoms exacerbated by work related conflict due to persistent tardiness. Her anxiety is worsening her insomnia which is then causing the work tardiness issues. She will require continued intervention with a goal to improve sleep, reduce depression and anxiety and improve work performance. Will continue to monitor MIC to track progress.
What to Document: The assessment should summarize the patient’s presentation by integrating biological (e.g., medical history, substance use), psychological (e.g., mood, trauma, cognition), and social (e.g., relationships, environment) factors. Include Measurement-Informed Care (MIC) findings, such as standardized scores (e.g., PHQ-9, GAD-7), and interpret them within the broader biopsychosocial context to support your clinical impression and treatment plan.
Best Practices:
- Combine symptoms, history, and MIC scores into a clear summary.
- Explain how MIC scores relate to the patient’s overall situation.
- Keep it simple and focused; avoid just listing details.
- Update the assessment as new information comes up.
- Use a professional tone and show understanding of the patient’s experience.
Plan:
Example:
- Discussed various treatment options with patient and decided to increase sertraline dose to 100 mg/day to treat anxiety and depressive sx
- Continue weekly CBT sessions focusing on stress management.
- Recommend sleep hygiene practices, including avoiding screens before bed and establishing a regular sleep schedule to address insomnia.
- Encourage participation in a CBT program that focuses on insomnia management. Link to be emailed to pt.
- Follow-up in two weeks to reassess anxiety and depressive symptoms and monitor medication response.
What to Document:
Medications: List medication name, dose, frequency, and changes with rationale. Include any needed labs or monitoring (e.g., blood work, EKG).
Therapy and Skills: Recommend therapy type (e.g., CBT) and frequency. Suggest coping strategies (e.g., mindfulness, journaling).
Referrals and Support: Note any referrals (e.g., therapy, case management). Encourage use of support systems (e.g., family, peer groups).
Safety: Document safety plans and crisis resources (e.g., 988 Suicide Hotline).
Follow-Up: Specify next appointment date and areas to monitor at follow-up. Include information on how to reach the provider should questions arise prior to the next scheduled appointment.
Best Practices:
- Outline medications (initiation or modifications), therapy goals, and behavioral interventions with reasoning.
- Provide specific follow-up instructions.
- Include discussion of relevant medication considerations (side effects, expected onset of improvement)
- Schedule next appointment in session with the patient
- Should exhibit evidence of shared decision making, e.g., “patient in agreement with plan of care”
After-Visit Summary (AVS):
Example:
- Visit summary: Today’s visit focused on addressing your continued struggles with anxiety. Our plan is to increase the dose of your anxiety medication to better target your anxiety symptoms.
- Medication Instructions: Increase sertraline to 75 mg daily with food (1.5 tabs) for 3 days then increase to 100mg daily with food. Monitor for side effects such as nausea or dizziness. Remember that it may take a few days to adjust to the medication and that it can take 4-6 weeks to see maximal benefits from the dose increase.
- Next Appointment: Follow-up in two weeks on [date].
- Resources Provided: Handout on sleep hygiene, CBT-I course info and local support group information.
- Safety information: 988, crisis text line, safety plan on fridge, 911 if feeling unsafe, Rula after hours crisis line.
- Contact information: Provider can be reached for any questions prior to next visit by email using xxx
What to document:
- Diagnosis: A brief explanation of the patient’s diagnosis or presenting concerns.
- Treatment Plan: Medications prescribed or adjusted, therapy recommendations, and any follow-up tasks (e.g., labs or referrals).
- Goals: Clear, simple goals for the patient to focus on (e.g., coping strategies or lifestyle changes).
- Safety Information: Crisis resources like the 988 Suicide Hotline and local crisis text lines.
- Next Steps: Date and time of the next appointment and what will be reviewed.
- Provider Contact Information: Include the provider’s name, contact details, and instructions for reaching out if needed.
Best Practices:
- Ensure patient leaves with clear, actionable steps.
- Reinforce medication adherence and follow-up timelines.
- Provide contact information for provider as well as emergency/safety information
Additional resources:
- Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition. (2024). The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults.
- Staus, C. (2022). Documentation: Your Very Best Defense. Psychiatric News, 57(4).
- APA evaluation and management (E/M) documentation handouts
- American Psychological Association, APA Task Force on Psychological Assessment and Evaluation Guidelines. (2020). APA Guidelines for Psychological Assessment and Evaluation. Retrieved from linked here.
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