Psychiatry
Psychiatry progress note template
A mental health progress note structured around the mental state examination and an explicit, dated risk assessment — the two elements reviewers look for first.
Best used for
- Outpatient psychiatry reviews
- Medication management visits
- Therapy progress notes
- Community mental health
Template structure
Each section shows what to document and a worked clinical example.
Changes since the last visit: symptoms, sleep, appetite, substance use, adherence, stressors, and function at work, study or home.
Example
Two weeks since last review. Mood improved from 3/10 to 6/10. Sleeping six hours, previously three. Taking sertraline daily without missed doses. Returned to part-time work. No alcohol.
Appearance and behaviour, speech, mood and affect, thought form and content, perception, cognition, insight and judgement.
Example
Well kempt, cooperative, good eye contact. Speech normal rate and volume. Mood 'better', affect reactive. Thought form linear, no delusional content. No perceptual abnormality. Cognition grossly intact. Insight good.
Address suicidal ideation, intent, plan and means; self-harm; risk to others; protective factors; and the resulting risk level. Never leave this section implied.
Example
Passive thoughts of being better off dead, no intent, no plan, no access to means. No self-harm since last visit. No thoughts of harming others. Protective factors: partner support, employment, engaged with treatment. Current risk assessed as low.
Medication decisions with dose and rationale, therapy actions, the agreed safety plan with named crisis contacts, and the review interval.
Example
Continue sertraline 100 mg daily. Continue weekly CBT. Safety plan reviewed: contact partner, then crisis line, then emergency department if thoughts escalate. Review in four weeks, sooner if deterioration.
Documentation tips
- Document the risk assessment at every visit, including when risk is low — absence of documentation reads as absence of assessment.
- Quote the patient's own words for mood and thought content where clinically relevant.
- Record the exact medication decision and the reason for it, not just the current list.
Frequently asked questions
- What belongs in a psychiatric mental state examination?
- Appearance and behaviour, speech, mood and affect, thought form and content, perception, cognition, and insight and judgement.
- How should suicide risk be documented?
- Explicitly, at every encounter: ideation, intent, plan, access to means, protective factors, the resulting risk level, and the safety plan agreed.
- Is ambient AI appropriate for mental health consultations?
- Only with the patient's consent and clinician review. ScribeMDPro does not retain audio, and the clinician approves the note before it enters the record.
- Can I use this template for therapy notes?
- Yes, though therapy notes typically add the intervention used, the patient's response, and progress against agreed goals.
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