Psychiatric Progress Note Template With 2 Full Examples

A psychiatric progress note template has a harder job than a therapy note template. A medication follow-up has to show what changed since the last visit, what the client takes and how, what you asked about side effects and safety, what you decided and why, and, if you bill an E/M code, enough of your medical decision making that someone else can follow it. Below you'll find a template you can copy, one field per line, and two complete notes from invented visits: a video follow-up with a dose change and a call to the client's therapist, and an office visit with a stimulant, a PDMP check and psychotherapy added on. After the examples: how the 2021 E/M rules and the psychotherapy add-on codes shape what you write, what to record for controlled substances, how to coordinate with a therapist, and the mistakes that make a note hard to defend.

It's written for psychiatrists, psychiatric nurse practitioners and other prescribers in private practice, and for therapists who share clients with them. Every client in this article is invented. Any resemblance to a real person is a coincidence.

What is a psychiatric progress note?

A psychiatric progress note records one follow-up visit with a client you already treat. The first visit is a full psychiatric evaluation: history, diagnosis and a starting plan. Every visit after it gets a progress note, which prescribers also call a follow-up note or a medication management note. Its job is narrower than the evaluation's: what changed since last time, how the treatment is working, whether it is safe to continue, and what you decided.

Compared with a therapy progress note, a psychiatric note spends more lines on medications, side effects, physical health and the reasoning behind each prescribing decision, and fewer on session content. It still needs a mental status exam and a risk assessment at every visit. When you also provide psychotherapy in the visit, the note gets a second part for it, with its own time.

None of this is a psychotherapy note under HIPAA. The definition of psychotherapy notes "excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests," and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date (45 CFR 164.501). That is the whole of a medication management note. It belongs in the record, the client can generally ask for a copy (45 CFR 164.524), and it should read well if they do. The difference is covered in detail in psychotherapy notes vs progress notes.

What goes in each section of the note

The order below follows how most follow-up visits run. Keep the same order in every note, so the next reader, including you in four weeks, finds things in the same place.

Visit details

Date, start and end time or total time, whether you saw the client in person, by video or by audio only, who was present, and for telehealth, where the client was during the visit. Clinicians must "be licensed or legally permitted to practice in the state where the patient is located" (HHS, Licensure for behavioral health), and many payers also ask for the format.

Interval history

What happened since the last visit, in the client's words where it helps. Cover the target symptoms you are treating (sleep, mood, energy, worry, focus, voices), how the client is functioning at work, school or home, life events, any emergency room visits or hospital stays, and anything new from other clinicians. Open with the chief concern in one line, for example: "Here for medication follow-up; says the new dose 'took the edge off but I'm still dragging.'"

Current medications and adherence

List every psychiatric medication with its dose, schedule and the date of the last change, then the other medications and supplements, because interactions don't care which prescriber started a drug. Ask how the client actually takes each one: missed doses in the past week, a different time of day than prescribed, split tablets, running out early, cost or pharmacy problems. "Taking as prescribed" only helps when you also write how you know.

Side effects

Record what you asked about, not only what the client volunteered. For an SSRI that might be stomach upset, sleep, sexual side effects and restlessness; for a stimulant, appetite, sleep, heart rate, blood pressure and anxiety; for an antipsychotic, weight, movement symptoms and sedation. Write the negatives you asked about ("denies sexual side effects when asked") as well as the positives, with severity and whether the side effect is changing how the client takes the medication.

Review of systems, vitals and labs

A psychiatric review of systems covers the symptom groups that could change your diagnosis or plan: depression, mania or hypomania, anxiety, psychosis, sleep, appetite and eating, substance use and attention. Add a medical review of systems when the medication calls for it. Record vitals if you took them, or home readings labeled as reported by the client, and every lab or outside result you reviewed with its date: a lithium level, a metabolic panel for an antipsychotic, a thyroid test from primary care, an EKG.

Measures

Rating scales turn "a bit better" into a number you can compare. The PHQ-9 for depression and the GAD-7 for anxiety are the common ones in outpatient care. Write today's total next to the previous total and its date. The PHQ-9 runs from 0 to 27, with scores of 5, 10, 15 and 20 marking mild, moderate, moderately severe and severe depression (Kroenke 2001); the GAD-7 runs from 0 to 21, with cut points of 5, 10 and 15 for mild, moderate and severe anxiety (Spitzer 2006). You can add up a total with the PHQ-9 scoring calculator and the GAD-7 scoring calculator. Any answer above 0 on item 9 of the PHQ-9 goes straight into your risk assessment.

Mental status exam

A brief mental status exam at every visit: appearance, behavior, speech, mood in the client's words, affect, thought process, thought content, perception, cognition, insight and judgment. A follow-up MSE can be short, but give each domain a specific descriptor instead of "WNL". The mental status exam template has descriptor lists for each domain.

Risk assessment

Ask about thoughts of suicide and of harming others at every visit, and write what you asked and what the client said. If the answer is yes, record frequency, plan, intent, preparation, past attempts, access to means (including firearms and saved-up medication, which matters more when you are the prescriber), risk and protective factors, your reading of the risk level and what you did about it. A screener such as the C-SSRS gives the questions a fixed form; the C-SSRS screener guide shows how to record the answers. When risk is raised, a written safety plan belongs in the Plan.

Assessment

This is the section that justifies the visit. For each problem you addressed, write the diagnosis with its code, whether the client is better, the same or worse compared with the treatment goal, and your reasoning. Say whether a symptom is the illness, a side effect or something else ("insomnia started before the dose increase, so it is unlikely to be a side effect"), and why you are changing treatment or keeping it the same. One line per problem is rarely enough; two or three sentences usually are.

Plan

Write the plan so a colleague covering for you could carry it out:

Psychiatric progress note template you can copy

Paste this into a blank note, delete what doesn't apply, and keep the order. The header lines come first because they're what a reviewer checks before reading anything else. The same fields work as a psychiatric follow-up note template, a medication management note template or a PMHNP progress note template: the content of a good note doesn't change with the prescriber's license.

Psychiatric progress note example 1: a medication follow-up by video

Invented client: a 46-year-old bus dispatcher we'll call Lorraine, treated for recurrent depression. She sees a therapist at another practice every week for CBT, and a signed release lets the two clinicians talk.

Chief concern: "The higher dose helped, but I'm still dragging by the afternoon."

Interval history: Seen four weeks ago, when sertraline was increased from 50 mg to 100 mg daily. Reports her mood is "better most mornings," she is back at work full time, and she has started walking with a neighbor twice a week. Still tired by mid-afternoon, has stopped cooking dinner most nights, and says she "can't get interested" in her grandchildren's soccer games. Sleeping about 6.5 hours a night (5 at the last visit). No emergency visits or hospital stays. No new stressors.

Medications: Sertraline 100 mg every morning, at this dose since 9/24. Lisinopril 10 mg daily, prescribed by primary care. No supplements and no other changes.

Adherence: Missed one dose in four weeks, which she checked against her pill organizer; now uses a phone alarm.

Side effects: Mild nausea in the first week after the increase, now gone. Asked about sexual side effects, headaches, sweating, restlessness and easy bruising: denies all.

Substance use: One glass of wine on weekends, unchanged. No cannabis or other drugs.

Review of systems: No periods of elevated mood, reduced need for sleep or racing thoughts. No psychotic symptoms. Appetite normal; weight stable by her report.

Results reviewed: Primary care note from 10/06; thyroid test (TSH) from the same day within normal limits.

Measures: PHQ-9 total 12 today (14 on 9/24, 19 at intake on 8/27). Item 9 scored 0.

Mental status exam: Casually dressed and well groomed, on camera from her kitchen. Cooperative, good eye contact. Speech normal in rate and volume. Mood "better, but not right yet." Affect mildly constricted, brighter when she talked about her walks. Thought process linear and goal-directed. No suicidal or homicidal thoughts and no delusions. Denies hallucinations and does not appear to be responding to internal stimuli. Alert, oriented, attention intact in conversation. Insight and judgment good.

Risk: Asked directly about thoughts of death or suicide since the last visit: "No, nothing like that." No past attempts. No firearms in the home. Keeps one week of medication in her pill organizer and the rest in a kitchen cabinet. Protective factors: her grandchildren, her job, and engagement in two treatments. Risk judged low and unchanged from her baseline.

Coordination: Spoke with her therapist by phone on 10/20 (release on file, signed 8/27). The therapist reports she completed behavioral activation homework three of the last four weeks, and that low interest in the evenings is the main target left in therapy. Agreed the therapist will keep evening activities as the focus while the medication is adjusted.

Assessment: Major depressive disorder, recurrent, moderate (F33.1). Partial response to sertraline 100 mg: the PHQ-9 has fallen from 19 to 12 over eight weeks, with better sleep and a return to full-time work, but low energy and loss of interest remain, and she is not at the treatment goal of a PHQ-9 below 5. Side effects were mild and short-lived and adherence is good, so a further increase is reasonable before a switch or an added medication. A normal TSH makes a thyroid cause of her fatigue less likely. Low risk of suicide at this time.

Plan:

MDM: Problems: one chronic illness not at its treatment goal. Data: discussion of management with her outside therapist; review of an outside note and a test result. Risk: prescription drug management.

Why this note works:

Psychiatric progress note example 2: psychotherapy added to a medication visit

Invented client: a 31-year-old architecture graduate student we'll call Theo, treated for ADHD and generalized anxiety. He doesn't see a separate therapist, so you provide brief CBT in his visits.

Chief concern: "The medication works for my focus, but I'm worried all the time about my thesis review."

Interval history: His thesis review is in three weeks. Focus and task completion "much better" on the current dose; he finished two design boards on time this month. Worries most of the day about failing the review and losing his funding, lies awake about 45 minutes on two or three nights a week, and has tight shoulders most days. Says the worry is no worse in the hours after his morning dose than later in the day. No emergency visits.

Medications: Methylphenidate extended release 36 mg every morning, unchanged since June. No other prescription medications. Takes a multivitamin.

Adherence and use: Takes his dose at 8 AM most days and skips it about one weekend day a week by choice. Denies taking extra doses, sharing or selling his medication, or needing early refills. Keeps it in a locked drawer because he lives with roommates.

Side effects: Less appetite at lunch, so he eats a large breakfast and dinner; weight stable. Asked about palpitations, chest pain, headaches, irritability as the dose wears off, and tics: denies all.

Substance use: Four to five cups of coffee a day for the past two weeks (two before that). Two drinks on Saturdays. No cannabis or other drugs.

Vitals: BP 124/78, HR 86, weight 171 lb (172 lb in July).

PDMP: State PDMP checked 10/23. Methylphenidate ER 36 mg, #30, filled every 28 to 31 days at one pharmacy, prescribed only by this practice. No other controlled substances on record.

Measures: GAD-7 total 14 today (9 on 9/25).

Mental status exam: Neatly dressed, sitting forward, jiggling his foot through most of the visit. Speech slightly fast, normal volume, easy to interrupt. Mood "stressed." Affect anxious, full range, appropriate to content. Thought process linear; thought content focused on the review, with no obsessions and no suicidal or homicidal thoughts. No hallucinations. Alert, oriented, attention good during the visit. Insight and judgment good.

Risk: Asked about thoughts of death or suicide: denies, now and in the past. No past attempts. No firearms. C-SSRS screener negative on every item. Risk judged low.

Psychotherapy (CBT, 2:20 to 2:47 PM, 27 minutes): Reviewed his worry log from the last visit, kept on four of seven days. Identified the main prediction, "If the review goes badly, I lose my funding," and weighed the evidence with him: his advisor's written feedback has been positive, and his program allows a second review. He rated his belief in the prediction at 85% before and 50% after. Introduced scheduled worry time: 15 minutes at 6 PM, writing worries down during the day and postponing them to that slot. Practiced one postponement in session. He said it "feels strange but doable."

Assessment:

Plan:

MDM: Problems: one chronic illness that is worse (anxiety) and one stable chronic illness (ADHD). Risk: prescription drug management.

Why this note works:

Writing it as a psychiatric SOAP note

Many practices and record systems want SOAP. The same content maps onto it cleanly:

So a psychiatric SOAP note example is example 1 above with these four headings added. For therapy sessions, see the SOAP note therapy examples, and the progress notes cheat sheet has clinical wording for MSE and response lines.

How E/M coding shapes the documentation

This section explains what the coding rules ask a note to show. It isn't billing advice: payers add rules of their own, and code selection is your call or your biller's.

Most outpatient medication follow-ups are reported with the office or other outpatient E/M codes (99212 to 99215 for established patients). Since January 1, 2021, the AMA's guidelines have let you select the level by "the level of the MDM as defined for each service, or the total time for E/M services performed on the date of the encounter" (AMA, 2021 E/M guidelines). The history and exam still have to be "medically appropriate," but "the extent of history and physical examination is not an element in selection of the level" of these codes. CMS applies the same framework: "The CPT E/M guidelines for MDM apply," and your history and exam "don't affect visit level selection" (CMS, MLN006764). CMS also reminds you that "medical necessity is the primary reason we pay for a service."

The same AMA guideline says the care team or the client can supply information "by electronic health record [EHR] portal or questionnaire" that the clinician then reviews. That is how a PHQ-9 filled in before the visit enters the note.

The three elements of medical decision making

MDM has three elements, and "two of the three elements for that level of MDM must be met or exceeded" (AMA). Each one maps onto part of the note:

The American Psychiatric Association's quick guide to the 2021 changes adds psychiatric examples to the AMA table: "Management of psychiatric medications" at moderate risk, and "Management of Clozapine," "Initiation of Lithium" and "Consideration of inpatient behavioral health admission" at high risk (APA quick guide). In the AMA table, moderate MDM sits beside 99214 for an established patient and high MDM beside 99215. Both invented examples above show moderate problems and moderate risk, which is why their MDM lines name those two elements.

Selecting by time

If you select a medication-only visit by time, the AMA counts "the total time on the date of the encounter," face to face and not, including "preparing to see the patient," "ordering medications, tests, or procedures," "referring and communicating with other health care professionals (when not separately reported)," "documenting clinical information in the electronic or other health record" and "care coordination (not separately reported)." It excludes travel and "the performance of other services that are reported separately." CMS asks you to "document the medical record with the time spent with patient using a start and stop time or the total time" (CMS, MLN006764). Write the total and a short list of what it covered.

Adding psychotherapy: 90833, 90836 and 90838

When you provide psychotherapy in the same visit as an E/M service, the psychotherapy is reported with an add-on code instead of a stand-alone one. CMS's coding manual puts it this way: "There are separate codes for psychotherapy without E&M service (CPT codes 90832, 90834, 90837) and Add-on Codes (AOCs) (CPT codes 90833, 90836, 90838) for psychotherapy to be reported in conjunction with the appropriate E&M code" (CMS, NCCI Policy Manual, Chapter XI). A Medicare billing article in CMS's coverage database sets out what that means for documentation: "To report both E/M and psychotherapy, the 2 services must be significant and separately identifiable." It goes on: "The type and level of E/M service is selected based on medical decision making. Time spent on the activities of the E/M service is not included in the time used for reporting the psychotherapy service. Time may not be used as the basis of E/M code selection" (CMS Medicare Coverage Database, A57480). The APA's guide says the same: "Time cannot be used to determine E/M when adding on psychotherapy."

For the note, that means three things:

Payers differ on the details. One Medi-Cal plan, for example, denies the add-on codes when billed with 99214 or 99215 on the same day, and requires that the time for the two services show "no overlap" (Blue Shield of California Promise, PI0061). Read your contracts, or ask a coder who knows your payers.

Documenting controlled substances and the PDMP check

When you prescribe a controlled substance, such as a stimulant for ADHD or a benzodiazepine, the note should show the checks you're required to do. For clients on Medicaid, federal law requires states to make covered prescribers check the client's history in a qualified prescription drug monitoring program (PDMP) "before prescribing to such individual a controlled substance." Here that means Schedule II drugs and, at the state's option, Schedule III or IV. When a prescriber can't run the check despite a good faith effort, the state "shall require the provider to document such good faith effort, including the reasons why the provider was not able to conduct the check" (42 U.S.C. 1396w-3a). State law sets its own PDMP rules for clients with other coverage, including which drugs and how often, so check your state's.

What to write at each visit where you prescribe one:

Prescribing a controlled substance after a telehealth visit has its own federal and state rules. Record the visit format in the note, and check the rules in force on the date you prescribe.

Coordinating with the client's therapist

Many clients see a therapist for psychotherapy and a prescriber for medication. Each clinician's note gets better when the other's view is in it.

For prescribers: write the date and source of anything the therapist reported, whether a release is on file if you rely on one, and what the two of you agreed. A call, or a back-and-forth exchange finished within a day or two, is the kind of discussion the AMA definitions count; sending a copy of your note isn't.

For therapists, the prescriber needs a short update, not session content:

HIPAA lets a covered provider disclose protected health information "for treatment activities of a health care provider" without the client's authorization (45 CFR 164.506). Many practices still use a signed release, and state law or the federal rules for some substance use disorder treatment records (42 CFR Part 2) can require one. Psychotherapy notes, if you keep them separately, generally need the client's authorization before you share them (45 CFR 164.508). The release of information form has a template where you name the other clinician, the purpose and an expiration date or event.

Common mistakes in psychiatric progress notes

Most weak notes fail in the same few places:

How this works in TranqBay

TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions and session notes in one account. For prescribers and the therapists who work with them, the parts that matter for follow-up visits are:

Prescriptions and PDMP checks happen in your prescribing system and your state's PDMP. Record each check in the note, as in example 2.

Frequently asked questions about psychiatric progress notes

Before the next follow-up

Copy the template, read the last note's Plan before the client arrives, and write today's note against it: last dose, last score, last risk reading, then what changed. A reviewer, a covering colleague or the client's therapist should be able to follow your reasoning from one visit to the next.

If you want follow-up visits, video sessions, forms and notes in one place, see how TranqBay works for private practice: you can look at a practice website template and the booking page clients would use for a follow-up. If you're deciding whether to join, this page explains how joining TranqBay works.

Sources