Complete a Psychiatry Progress Note

TherapyNotes' Psychiatry Progress Note template allows you to effectively document medication management and counseling or other services within a single note.

Psychiatry Progress Notes are connected to appointments with Psychiatry Session selected as the Appointment Type. Once a scheduled Psychiatry Session begins, TherapyNotes will generate a To-Do list item to create the corresponding Progress Note. To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note.

Note Header

The note header automatically fills in information for the clinician, client, and appointment, including relevant supervision information, client insurance, and service code. To edit information in the note header, such as the Note Title or Service Code or to add information such as add-on codes, click anywhere on the note header or click Edit in the upper right corner.

Diagnosis

The diagnosis information will automatically be brought forward from the most recent note the clinician wrote for this client. This time-saving feature makes it easier to create a note, while also reducing errors in documentation. If you need to edit or update a client’s diagnosis, you can begin typing in the ICD-10 field if you know the appropriate code or begin typing the description if you do not. These fields also feature searchable DSM-5 diagnoses, allowing you to easily find diagnoses.

Current Mental Status

Here you can document a mental status exam. Use our one-click auto-fill options (All Normal or All Not Assessed) to simultaneously fill each of the fields, or click in each field to select from a list of common responses or enter your own information.

Risk Assessment

The risk assessment section is comprehensive and in line with best practices, especially around assessing suicidality. It is easy to document the full scope of clinical assessment, while also incorporating best practices from risk management to serve both you and your clients more efficiently.

Patient denies all areas of risk

When the client denies all areas of risk and your clinical judgment concurs, select the Patient denies all areas of risk. No contrary clinical indications present checkbox at the top of the Risk Assessment section. This shows that you did not simply accept the client denial of risk, but you performed a suitable clinical assessment as well

Area of Risk

Clicking in this field will allow you to readily select from a variety of common areas of risk. You are also able to type any other or more specific areas of risk for your client. You should enter only one area of risk per field so that each area can be assessed independently.

Level of Risk

An area of risk may be present for your client, it does not mean it poses an immediate or grave threat. Level of Risk lets you rate risk as Low, Medium, High, or Imminent, and shows variance in risk over time, providing effective documentation of improvement or times of crisis. Because each area of risk is assessed independently, you can also quickly show where differences exist. This field will be required for all areas of risk.

Intent, Plan, and Means to Act

Documenting these items helps justify your selection of the level of risk and shows that you completed a thorough assessment. Because some items may not apply to some types of risk, each item has Not Applicable as an option. Each item will require a selection for all areas of risk.

Risk and Protective Factors

Click in these fields to display a list of relevant common factors that may increase or decrease your clients’ level of risk. Choose as many as apply to each area of risk or add your own items specific to your client.

Additional Details

Enter any relevant additional details not already addressed in other sections.

Add Multiple Areas of Risk

If multiple areas of risk apply to your client, you can document each area separately. Use the +Add Area of Risk link at the bottom to add another set of fields to the note template. You can reorder these groups or remove them entirely by using the up/down arrow and "X" to the right of each Area of Risk. Unless the Patient denies checkbox is selected, there must always be at least one set of fields. Clicking the “X” will not remove the fields if there is only one group but will clear out all existing entries and allow you to start over.

Vital Signs

You can choose to document as many or as few vital signs as you measured in session. For fields such as height, weight, and temperature, select the appropriate units for your measurement from the dropdown menu first. TherapyNotes will remember which units you use in future notes. Use the slider to document the client-reported level of pain.

Physical Exam

Record your findings from a physical exam here, such as HEENT, pulmonary, cardiovascular, neurologic, general, or other findings.

Review of Systems

To make it easier to document effectively for E/M coding, record any information about your review of systems here. The placeholder text provides a prompt of a psychiatric review of systems, but you can also choose to document a more traditional review of systems (constitution, HEENT, pulmonary, CV, etc.).

Symptom Description and Subjective Report

This is the field to document any subjective information shared by the client in session. This could include information such as their experience of symptoms, effects of medication, and relevant events that occurred since the previous session.

Objective Content

This field is for documenting objective information, such as findings, topics of discussion, narrative information about interventions, and other things that could be observed or measured in session.

Allergies

List any actual or suspected allergies the patient may have here. You can document the type of reaction and its severity for each allergen. You may also choose to document adverse drug reactions in this field.

Response to Medication

This field can provide a more detailed analysis of the patient response to medication than in the Subjective section above. This may be a good place for recording responses to trials of previous medications, reasons for switching classes, how the patient is tolerating effects, and other information related to the medication history for the client. With the History function readily available, it will be easy to see previous medication trials and outcomes or provide information necessary for a prior authorization.

Medication Reconciliation 

This section includes medications prescribed by others, existing medications, and medication changes.

Prescribed by Others

Use these fields to document medications the patient is currently taking that are prescribed by other providers. Typing in the Medication field will allow you to search a list of common psychiatric medications, or you can type the full name of the medication. Enter the dosage and frequency of administration. Clicking in the Symptoms Being Treated field will give a list of common symptoms to select from and you can type additional information as well. Enter the prescribing provider’s name in the last column. As you type, an additional row will automatically appear allowing you to document as many medications as necessary.

Existing Prescribed Medication

If you have documented medications that you have prescribed on a previous note, such as a Psychiatry Intake or Psychiatry Progress Note, those medications will automatically be brought forward for you. This will make it easier to see what the patient is currently prescribed with no effort on your part.

Medication Moving Forward

Use these fields to document changes to medications you make in session.

Comments Regarding Medications

Here you can document any specific discussions you had with the patient about their medications. You can also document any interactions they may experience, any probable side effects, plans for titrations, rationale for selecting specific medications or classes, or any other relevant information. Use the checkbox to quickly document that you discussed any changes in medications with the patient.

Assessment

Use this field to capture a global assessment of patient change compared to their previous visit. Click into the field to select from a list of options, or type anything else you need.

Plan

Document the next steps in the treatment process, whether it is to contact other providers to obtain records, coordinate with primary care, or just follow up with the patient at a later date.

Recommendation

Use this field to document your recommendation for treatment moving forward. Selecting Terminate treatment will prompt you to complete a Psychiatry Termination Note.

Prescribed Frequency of Treatment

Use this field to capture how often this patient should be seen for treatment.

Sign and Save

Once you have completed your Progress Note for the session, select the Sign this Form checkbox to electronically sign the note and click the Create Note button. Electronic signatures are captured in accordance with appropriate requirements.  

Multiple factor authentication is required to identify the user signing the note. The application automatically captures the timestamp for the signature as well. Electronic signatures cannot be edited or modified. If the document is placed in draft mode and then re-signed, the signature on the note will reflect the most recent electronic signature captured. You can view other signatures, including the timestamp of the first signature on the note, using the Note Revision History. All actions related to note signatures are captured in the activity log for the practice.

To save an unfinished Progress Note, leave Sign this Form unchecked and click the Save Draft button. You may access your draft Progress Note later from your To-Do list or click Patients > Patient Name > Documents tab.