Elevate Mental HealthDocumentation withClinical Precision
In psychiatry, every word matters. Whether assessing mood disorders, managing medications, or responding to crisis risks, psychiatrists require documentation that is structured, defensible, and clinically insightful.
Purpose-Built: The SCRIBE AI Psychiatric Template helps streamline this process—supporting accuracy, accountability, and continuity of care across outpatient, inpatient, and emergency settings.
🧾 Why a Psychiatric Template Matters
Psychiatric documentation isn't just about symptom tracking—it's a comprehensive record of mental status, diagnostic impressions, pharmacologic interventions, and risk management.
Standardized documentation
High-quality documentation across all visits with consistent structure
Medication tracking
Precise tracking of diagnostic evolution and medication response
Risk documentation
Clear risk documentation (SI/HI, psychosis, hospitalization needs)
Legal protection
Legal protection and billing compliance with audit-ready documentation
Interdisciplinary collaboration
Enhanced collaboration with therapy, social work, and primary care
🧑⚕️ Who Uses This Template?
Psychiatrists
(MD, DO)
Psychiatric Nurse Practitioners
(PMHNPs)
Physician Assistants
in Psychiatry
Forensic Psychiatrists
& Addiction Specialists
Crisis Clinicians
& Consult-Liaison Teams
🧩 Inside the Psychiatric Template
This template supports psychiatric evaluation, medication management, and follow-up sessions, balancing thoroughness with clarity.
Identifying & Visit Information
Includes demographic details, date/time, provider, and visit type
Example:
"Visit Type: Medication Management Follow-up | Duration: 25 mins"
Chief Complaint / Presenting Problem
The reason the patient is seeking care, in their own words
Example:
"I'm still not sleeping and my anxiety is worse at night."
History of Present Illness (HPI)
A detailed account of current symptoms, progression, triggers, treatment response, and functioning
Key Components:
- Mood, sleep, appetite, energy
- Psychosis, anxiety, suicidal/homicidal thoughts
- Medication adherence and side effects
- Functional impact on work, school, relationships
Psychiatric Review of Systems (ROS)
Systematic check for presence/absence of symptoms
Key Components:
- Depression, Mania, Anxiety
- Hallucinations, Delusions
- Sleep, Appetite, Substance Use
- Impulsivity, Concentration, Irritability
Mental Status Examination (MSE)
Structured observations made during the encounter
Key Components:
- Appearance, Behavior, Speech
- Mood and Affect
- Thought Process/Content
- Cognition, Insight, Judgment
- Orientation, Attention, Memory
Example:
"Well-groomed, cooperative. Mood 'okay,' affect constricted. Thought process logical. No SI/HI."
Diagnosis / Assessment
Clinical impression, DSM-5 diagnosis(es), and diagnostic reasoning
Key Components:
- Diagnostic codes (ICD-10)
- Differential diagnoses if applicable
- Response to current treatment
- Risk stratification and changes in condition
Example:
"F33.1 – Major depressive disorder, recurrent, moderate. Symptoms persistent; partial response to sertraline"
Plan / Interventions
Document pharmacologic and non-pharmacologic strategies
Key Components:
- Medications prescribed/adjusted
- Lab orders or referrals (e.g., therapy, neuro eval)
- Patient education and side effect review
- Safety planning or crisis interventions
- Next follow-up or monitoring plan
Example:
"Increase sertraline to 100mg. Monitor sleep and SI. Safety plan reviewed. Follow-up in 2 weeks."
🚫Common Pitfalls in Psychiatric Documentation
Inadequate risk documentation (SI/HI not addressed)
Lack of diagnostic updates despite evolving symptoms
No medication rationale or plan for side effect monitoring
Overreliance on templated text without clinical specificity
🧪 Use Case Examples
Medication Management Visit
Psychiatric Crisis Follow-Up
New Patient Evaluation
✅Best Practices for Psychiatric Notes
- ✓Always document SI/HI and psychosis assessments
- ✓Clearly link medication decisions to symptoms
- ✓Use DSM-5 diagnostic language and ICD codes
- ✓Include lab monitoring plans (e.g., lithium, antipsychotics)
- ✓Summarize medication education & patient consent
🛡️Billing & Legal Compliance
The Psychiatric Template supports:
- ✓CPT codes: 90791 (initial eval), 99213–99215 (med mgmt), 90833/90836 (therapy add-ons)
- ✓ICD-10 alignment for mental health diagnosis codes
- ✓Risk and crisis documentation for audits or hospitalizations
- ✓Ethical standards of APA, AMA, and licensing boards
Simplify Psychiatric Notes with SCRIBE AI
SCRIBE AI helps psychiatric providers streamline documentation and focus on patient care
Auto-fill MSE language
Standardized Mental Status Examination templates
Track medication changes
Monitor medication adjustments across visits
AI-generated summaries
Automated coding suggestions and clinical insights
Focus on patient care
Reduce paperwork time, increase patient interaction
Try the Psychiatric Template Now
In psychiatry, documentation is both a clinical tool and a protective shield. The SCRIBE AI Psychiatric Template ensures that your notes are accurate, compliant, and aligned with best practices.
🧬 Conclusion
In psychiatry, documentation is both a clinical tool and a protective shield. The SCRIBE AI Psychiatric Template ensures that your notes are accurate, compliant, and aligned with best practices—so you can spend more time treating, less time charting.
Document safely. Practice confidently. Choose SCRIBE AI.