Psychiatry progress notes: template, SOAP example and mental status exam

A psychiatric progress note is the record of one follow-up psychiatric visit: what the patient reports, the mental status exam, the clinician's assessment, and the plan for medication and therapy. When a prescriber adds psychotherapy to a medication-management visit, the same note documents both services, each separately identifiable. Most psychiatric practices write it in SOAP format.

This guide gives a copyable template, a worked SOAP example, a mental status exam template, and the rules for documenting an E/M visit with psychotherapy add-on 90833. The billing rules quote Medicare and its contractors. Commercial payers and Medicaid programs can differ, so check your contracts. The sources are listed at the bottom.

What goes in a psychiatric medication management note?

A medication-management visit is billed as an evaluation and management (E/M) service. The note covers:

• Interval history: symptoms since the last visit, response to medication, side effects, adherence, sleep, substance use, stressors.
• Mental status exam: observed findings, including suicidal and homicidal ideation. The template is below.
• Data: rating scales given, labs, drug levels, outside records reviewed.
• Assessment: each diagnosis, its status (stable, improving, worsening), and risk.
• Plan: medication changes with dose, monitoring, therapy, safety planning where indicated, and the follow-up interval.
• Psychotherapy, if provided: its time and content, documented apart from the E/M work.

Medicare's E/M booklet says these visits include a medically appropriate history or exam. The extent of the history and exam isn't what sets the level. For most E/M visits, the level is chosen by medical decision making (MDM) or by time.

MDM has three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of patient management. A level needs two of the three.

In the AMA's MDM table, prescription drug management is an example of moderate risk. So in a medication visit, the Assessment and Plan carry most of the weight. Name each problem addressed, what you reviewed, and the medication decision.

Psychiatry progress note template

Copy this into your EHR and delete what doesn't apply.

PSYCHIATRIC PROGRESS NOTE: FOLLOW-UP
Date:                     Visit: in person / telehealth
Services: E/M [ ]   Psychotherapy add-on [ ]
Psychotherapy time: ___ min (start–stop or total; excludes E/M time)

S: SUBJECTIVE
Chief concern:
Interval history since last visit:
Medication response, side effects, adherence:
Sleep, appetite, energy:
Substance use:
Stressors and supports:
Safety: suicidal ideation (intent, plan), homicidal ideation, self-harm since last visit:

O: OBJECTIVE
Vitals (if taken):
Mental status exam: (see MSE template)
Rating scales (if given):
Labs, drug levels, records reviewed:

A: ASSESSMENT
Diagnoses and status of each:
Risk assessment:
MDM: problems addressed / data reviewed / management risk

P: PLAN
Medications (name, dose, change, reason):
Monitoring:
Therapy (modality, focus, homework):
Safety plan and crisis resources (if indicated):
Coordination with other clinicians (with consent):
Follow-up:

PSYCHOTHERAPY (only when an add-on code is billed)
Time (start–stop or total):
Type (individual / family / interactive):
Techniques used:
Content and patient response:
Goals and progress:

Psychiatric SOAP note example

The patient below is invented. The example shows structure, not clinical advice.

Header. Established patient, follow-up, in person. E/M with psychotherapy add-on. Psychotherapy 2:18 to 2:40 pm (22 minutes), separate from the E/M portion.

S: 34-year-old with major depressive disorder, seen 6 weeks after sertraline was increased to 100 mg daily. Reports mood "better most days." Sleeping 6 to 7 hours. Back at work full time. Mild nausea in the first week, now resolved. Takes the medication daily. No alcohol or drug use. Worried about a job review next month. Denies suicidal ideation, intent or plan. Denies homicidal ideation.

O: Casually dressed, well groomed. Calm and cooperative, good eye contact, no abnormal movements. Speech normal in rate, volume and rhythm. Mood "better." Affect mildly constricted, reactive, congruent. Thought process linear and goal-directed. No suicidal or homicidal ideation, no delusions. No hallucinations reported or observed. Alert and oriented to person, place and time. Attention and memory grossly intact. Insight good. Judgment good. Depression rating scale score lower than at the last visit.

A: Major depressive disorder, improving on sertraline, tolerating the current dose. Anxiety focused on the upcoming review. No suicidal ideation. Engaged in treatment, with work and family as protective factors.

P:

• Continue sertraline 100 mg daily. No change today.
• Psychotherapy, 22 minutes: cognitive restructuring on the belief that one poor review means losing the job. Patient generated two alternative thoughts. Homework: thought record before the review.
• Crisis resources and the after-hours number reviewed.
• Follow up in 8 weeks.

Two things in this note support billing E/M plus 90833. The medication decision sits in the Assessment and Plan. The psychotherapy has its own time and its own content, and 22 minutes falls in the 90833 band.

Mental status exam template

The mental status exam is the psychiatric part of the physical exam. Each row gives what to record and wording you can adapt.

The same template as a list:

MENTAL STATUS EXAM
Appearance:
Behavior:
Speech:
Mood (patient's words):
Affect:
Thought process:
Thought content (SI / HI with intent and plan; delusions; obsessions):
Perception (hallucinations):
Cognition (orientation, attention, memory, fund of knowledge):
Insight:
Judgment:

Mood is what the patient reports. Affect is what the clinician observes. Record mood in the patient's words.

Medicare's 1997 E/M documentation guidelines list the same elements in their psychiatric exam: speech; thought processes; associations; abnormal or psychotic thoughts, including hallucinations, delusions, and homicidal or suicidal ideation; judgment and insight; orientation; memory; attention and concentration; language; fund of knowledge; and mood and affect. Office E/M levels no longer depend on the exam, but the list still maps onto the template above.

How do you document E/M with psychotherapy add-on 90833?

Prescribers who manage medication and provide psychotherapy in the same visit bill the E/M code and add 90833, 90836 or 90838. The add-on depends on psychotherapy time. Medicare contractor guidance sets these rules:

1. Both services must be significant and separately identifiable. A separate diagnosis isn't required for each.
2. Choose the E/M level by MDM. WPS, a Medicare contractor, says time may not be used as the basis of E/M code selection when psychotherapy with E/M is reported.
3. Psychotherapy time excludes E/M time. Time on E/M activities doesn't count toward the psychotherapy minutes. The AMA's E/M guidelines say the same in reverse: E/M time excludes time spent on other separately reported services.
4. Document the psychotherapy time. Record start and stop times or total time devoted to psychotherapy. It doesn't have to be continuous.
5. Use the time bands. 16 to 37 minutes for 90833, 38 to 52 minutes for 90836, 53 minutes or more for 90838.
6. Under 16 minutes, no psychotherapy code. Contractor guidance says not to report psychotherapy of less than 16 minutes.
7. No prolonged-service codes with the add-ons. Prolonged services can't be reported when 90833, 90836 or 90838 is billed.

For the psychotherapy itself, Novitas's coverage policy asks the record to show:

• the time spent in the psychotherapy encounter
• the type of service: individual, group, family or interactive
• the content of the session
• the therapeutic techniques and approaches, including medications
• who performed the service

The same policy adds that for services with an E/M component, the E/M services should be documented.

In practice, give the psychotherapy its own labeled block, as in the template: minutes, technique, content and response. Without the time, there's nothing to choose the add-on code from.

Where Caesar fits

• Drafts in your template. Caesar's AI Scribe drafts the progress note from the session into your practice's own template. The clinician reviews, edits and signs it.
• Reads the chart. The draft reads the patient's chart history. Prior records, such as an earlier clinician's summary, seed the chart as provisional facts that a provider accepts.
• Suggests psychotherapy codes. It suggests 90791 for an intake evaluation, and 90832, 90834 or 90837 from the session length. The clinician confirms the code. Psychotherapy CPT codes covers the full set.
• Files intake to the chart. Intake forms collect consent with an e-signature, and the completed form is filed to the patient's chart.

For therapist notes in DAP, BIRP and other formats, see therapy progress notes. How Caesar works with psychiatry and therapy practices.