If you received a Rula Documentation Feedback email, use this guide to learn about the most
common feedback categories and what they mean.
If any of these areas were flagged in your feedback email, that’s your cue to review and improve that part of your documentation moving forward.
Feedback category | What it means | Meets Expectations | Needs Improvement |
| Timely documentation | Documentation is completed within 48 hours of the session end time. | Visit on 1/2/26 at 7:00 AM; note signed and locked 1/3/26 at 6:15 PM | Visit on 1/2/26 at 7:00 AM; note signed and locked 1/5/26 at 10:00 PM |
| Chief Complaint | Document the patient’s main reason for seeking psychiatric treatment, ideally expressed in their own words. Each visit should have a unique chief complaint. | “I’m still feeling very anxious most days and want help adjusting my medication.” | Follow up Or Bipolar disorder |
| HPI | For intake notes, documentation should meet the full DSM-5 criteria for all ICD-10 codes selected, clearly demonstrating medical necessity. Be sure to include clinically relevant details that support each diagnosis—such as onset, duration, intensity, progression, triggers, coping strategies, and psychosocial stressors that provide context. For follow up notes, The HPI must reflect the patient’s current symptoms and clinical status at the time of the encounter, supporting the diagnosis. It should be specific to the visit and not duplicated from prior documentation. | Patient presents with a four year history of depressive symptoms including persistent low mood, anhedonia, low energy, impaired concentration, and feelings of worthlessness occurring most days. Depressive symptoms intensified over the past six months following increased work stress and financial strain. Patient also reports a three year history of anxiety characterized by excessive worry occurring most days, restlessness, muscle tension, and sleep disturbance, with symptoms worsening over the past several months. Coping strategies include avoidance and reassurance seeking, which provide minimal relief. Symptoms cause clinically significant impairment in occupational functioning and interpersonal relationships. Denies history of manic or hypomanic episodes. | Example 1: Patient here for an initial assessment for mood and anxiety. Symptoms ongoing. Wants to continue treatment with current meds. Example 2: Refer to prior note. No changes since last visit. Meds stable, denies new complaints. Example 3: Patient presents today for an initial psychiatric evaluation due to mood and anxiety symptoms. Patient reports ongoing depression and anxiety. Symptoms ongoing. Wants to continue treatment. Example 4: Update 1/02/26: Patient reports symptoms are about the same. |
| Measurement informed care* | MIC measures are completed by the patient prior to or during the session, if not completed ahead of the session. The provider is checking the box indicating measures were reviewed, and documentation is in the note (Assessment) regarding how the measures will be used to inform care. | PHQ-9 = 16 and GAD-7 = 14, indicating moderate depressive and anxiety symptoms. Scores reviewed and discussed with patient. Will monitor for improvement in MIC scores following increase in escitalopram to further target ongoing anxiety and depressive symptoms. |
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| Documentation of Parental Consent | Providers MUST legally obtain consent from the parent/guardian for any mental health medication initiation. Document parental/guardian consent to include the name of the individual. Additionally, providers must legally obtain consent for any medications prescribed for the first time or changes to existing prescriptions. The documentation should include details of how the parent participated in the visit If parental consent is obtained outside of the visit (e.g., by phone or secure email), the provider must document how consent was obtained, who provided it, and confirm that no medication changes were made until consent was received | Medication risks, benefits, and alternatives reviewed with mother, Jane Doe, who participated in the visit and provided consent for medication initiation. Reviewed risks, benefits, and alternatives of increasing escitalopram from 10 mg to 15 mg daily with mother, Jane Doe. Mother participated in the visit, asked questions, and provided consent for the dose increase. Following the visit, parental consent for increasing escitalopram from 10 mg to 15 mg daily was obtained via phone call with mother, Jane Doe, on 1/21/26 at 3:15 PM. Risks, benefits, and alternatives were reviewed. No medication changes were made prior to receipt of consent. Prescription was sent after consent was obtained. | Parental consent obtained No documentation of:
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| Medication History | Document current and previous psychiatric and relevant non psychiatric medications/OTCs (with dates of use and dosages if possible). | Current medications: escitalopram 10 mg daily (started 8/2025). Previous psychiatric medications include sertraline 50 mg daily (2022–2023, discontinued due to GI side effects) and aripiprazole 2 mg daily (2024, discontinued due to akathisia). Relevant non-psychiatric medications: levothyroxine 75 mcg daily. | “Has tried several antidepressants in the past.” “See medication list.” |
| Allergies | Always document and verify any allergies to medication | Penicillin (PCN) – rash and hives. Reaction occurred in childhood; no history of anaphylaxis. Allergy reviewed and verified with patient today. | (No entry documented) or NKDA Chart history: Prior visit lists PCN allergy |
| Physical Diagnosis History | Document chronic illnesses, surgeries, and hospitalizations. Include significant medical conditions that could affect mental health or medication management (e.g., thyroid disorders, neurological conditions). If the patient does not endorse any of the above please use “None” or “Denies” as opposed to N/A | History of hypothyroidism, well controlled on levothyroxine. Denies history of seizures, cardiac disease, head injury, or other chronic medical conditions. Denies prior surgeries or hospitalizations. | N/A |
| Psychiatric History | Ensure to document the following:
If the patient has no psychiatric history to document, please use “None” or “Denies” as opposed to N/A | History of Major Depressive Disorder and Generalized Anxiety Disorder. Denies prior psychiatric hospitalizations, IOP/PHP, or residential treatment. Denies history of suicide attempts or self-harm. Engaged in outpatient therapy intermittently in the past. Denies history of harm to others. | N/A |
| Family Psychiatric History | 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. If the patient has no family psychiatric history, please use “None” or “Denies as opposed to N/A | Mother with history of bipolar disorder. Father with history of alcohol use disorder. Denies known family history of schizophrenia, suicide, ADHD, or sudden cardiac death. | N/A |
| Client’s trauma history (neglect, violence, assault, abuse | 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 | Patient reports history of emotional abuse in childhood. Denies physical or sexual abuse. Trauma contributes to ongoing anxiety symptoms. Denies current suicidal ideation or homicidal ideation. Denies current safety concerns or exposure to violence. | N/A |
| Documentation of Social Supports | 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. Be sure to include the patient’s living situation and support systems, military history, legal issues, occupation and education. | Lives with partner and two children in a stable apartment. Reports supportive relationship with spouse and close friends. Employed full time as a medical assistant. Denies military history or current legal issues. | Single |
| Safety Plan Completion | 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. Complete a safety plan if C-SSRS indicates yes to question 3 or 6B and make sure the patient is given a copy | C-SSRS positive for suicidal ideation without intent or plan. Safety plan completed collaboratively with patient during the visit. Reviewed coping strategies, identified support persons, and provided crisis resources. Patient provided a copy of the safety plan. | Safety discussed. |
| Shared Decision Making | Shared decision-making is essential in mental health care as it empowers patients to actively participate in their treatment, promoting engagement, adherence, and improved outcomes through a collaborative, patient-centered approach. Document shared decision-making by noting how the patient was involved in their care (e.g., treatment options discussed) | Discussed treatment options with patient, including continuing current medication versus dose increase. Reviewed risks, benefits, and alternatives. Patient expressed preference to increase escitalopram dose to further target anxiety symptoms. Plan agreed upon collaboratively. | Patient instructed to increase medication. |
| PDMP Check | Providers are legally required to review the PDMP before prescribing any controlled substance and at least every six months thereafter. Document PDMP findings clearly in the patient’s note. | PDMP reviewed today prior to prescribing. PDMP reflects last fill of Adderall XR 20 mg on 01/02/2026, prescribed by current provider. No early refills, multiple prescribers, or other concerning controlled substance activity noted. | No concerns |
| Medication Adherence | Document whether the patient is adherent to their medication; if not, include the reason for nonadherence and the plan to improve adherence (e.g., changing medication due to side effects) | Patient reports missing escitalopram doses two to three times per week due to forgetfulness. Denies side effects. Discussed strategies to improve adherence, including medication reminders and once daily dosing. Plan to continue medication with adherence supports in place. | Non-compliant |
| Pregnancy Check | If the patient is female and of childbearing age, it is essential to assess pregnancy status or intent to become pregnant, as some psychiatric medications may pose risks during pregnancy. | Patient denies current pregnancy and denies plans to become pregnant at this time. Pregnancy risks related to current medications reviewed. | N/A |
| Assessment | The assessment should summarize the patient’s presentation, including:
| Patient with Major Depressive Disorder, recurrent, moderate and Generalized Anxiety Disorder presents for follow up with persistent anxiety and depressive symptoms. PHQ-9 score of 13 indicates moderate depressive symptoms, including low motivation and fatigue, and GAD-7 score of 14 indicates moderate anxiety with excessive worry and muscle tension. Biologically the patient demonstrates a partial response to escitalopram 10 mg daily with continued symptom burden, reports adequate adherence without significant side effects, and denies substance use or medical contributors impacting mood or anxiety. Psychologically, ongoing maladaptive worry patterns and cognitive distortions continue to contribute to symptom persistence. Socially, work-related stress remains a significant exacerbating factor. Measurement-Informed Care data reflects ongoing moderate symptom severity and is being used to guide treatment decisions, including medication adjustments, and will be monitored over time to assess response and inform future care. Patient aligned and in agreement with plan to increase escitalopram, with a discussion of risks, benefits and alternatives. | See HPI. Or Patient reports ongoing anxiety and depression related to work stress. Symptoms ongoing. Wants to continue treatment. |
| Plan | Ensure that your treatment plan includes:
| Diagnosis: Major Depressive Disorder, recurrent, moderate; Generalized Anxiety Disorder. Ddx: BPAD II -no hx hypomanic episodes reported. Symptom course, duration and presentation are most consistent with GAD and MDD. Increase escitalopram from 10 mg to 15 mg daily to further target persistent depressive and anxiety symptoms, given partial response at current dose and ongoing moderate PHQ-9 and GAD-7 scores. Continue psychotherapy focused on CBT-based strategies for anxiety and mood management. Monitor for medication tolerability, side effects, and symptom improvement. PHQ-9 and GAD-7 will be reassessed at follow up to evaluate response and inform ongoing care. Safety reviewed. Patient denies SI or HI. Safety plan and crisis resources discussed. Patient instructed to contact provider via the patient portal with concerns and to seek urgent or emergency care for worsening symptoms or safety concerns. Follow up scheduled in four weeks on 01/26/2026 to reassess symptoms, medication response, and functional status. | Increase medication dose. Follow up as needed Or Continue current treatment. |
| Appropriate Follow-Up Timeframe | Please ensure follow-up is scheduled within an appropriate timeframe based on the patient's acuity, needs and treatment response. Providers should exercise clinical judgment to ensure high-risk patients are not being under-scheduled and stable patients who require less monitoring are not being over-scheduled. | Pt reports worsening depressive symptoms with passive SI. Will increase lexapro to 20 mg daily Follow up plan: Follow up in 1-2 weeks or sooner if needed due to worsening symptoms. | Mood and anxiety symptoms stable on current medication. No medication changes implemented. Denies SI or HI. Follow Up Plan: Follow up weekly. |
| 90833: Therapy Add On | When documenting a therapy add on code, ensure to document the following: Patient’s diagnosis and a clear rationale for ongoing treatment, such as expected improvement or the need to maintain current level of functioning A summary of the psychotherapy session, including the specific therapeutic interventions utilized A summary of goals, patient’s progress toward goals, and any updates to the treatment plan An assessment of the patient’s engagement and/or response to psychotherapy | Provided 20 minutes of psychotherapy focused on anxiety management in the context of medication treatment. Utilized supportive therapy and CBT based techniques to explore cognitive distortions related to work stress and anticipatory anxiety. Reviewed coping strategies and grounding exercises to support anxiety reduction while medication adjustments are implemented. Patient was engaged and participatory. Ongoing psychotherapy remains indicated to support symptom improvement alongside pharmacologic treatment. | Psychotherapeutic interventions: Therapy provided, see HPI. Or 16 min of therapy provided |
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