Psychiatry Notes

Authored by Dr. Hannah Lin, a counseling psychologist trained in CBT, ACT, and IFS. She writes the documentation judgment beside the prescriber’s decision: which line holds the medication choice, and which line holds the therapy move.

Educational content for licensed clinicians. Not clinical, legal, billing, or licensure advice. Sign only the exam, the risk, and the medication decision your license lets you make.

The visit closed in twenty minutes. Last month’s note still says “continue current meds.” You have three missed mornings, a side effect they can live with, and a score that moved a little. Psychiatry notes for that hour are the eight sections above, plus the four lines that show how you would select the E/M level. Fill them from this visit. Then sign.

I read a collaborating prescriber’s note for the decision, not for the list. If the dose line says continue, I want the reason on the same line. If the reason is missing, the chart does not yet show that a medication decision was made. It shows a medication list.

When this skeleton fits

Use these psychiatry notes when the hour turns on a medication decision for an established outpatient. Psychiatric notes from a hospital consult need their own setting line, a different exam, and the admission rules of that unit. Do not stretch this office example into a consult.

A psychotherapy follow-up that does not turn on a prescription decision belongs on the psychiatric progress note template. That note still needs an interval, a current exam, named risk, and the next therapy move. It is the wrong shape once you are signing a dose.

A format-neutral therapy visit, with no prescription decision, belongs on the patient notes template. Seven lines, then a signature. The same PDF prints both skeletons. Fill the page that matches the hour.

A first diagnostic evaluation is a different note. For that evaluation, the Medicare NCCI manual uses 90791 when the psychiatric evaluation is without medical E/M and 90792 when it includes medical E/M, subject to the applicable payer rules (NCCI Chapter XI). Do not paste this follow-up into an intake because the headings look familiar.

What the E/M level actually reads

CMS, in the May 2026 Evaluation and Management Services booklet, says that as of January 1, 2023, you choose the visit level for most E/M families by medical decision making or by the time you spent. History and exam must still be medically appropriate. They do not select the level. The medical record should show the chief complaint. If you use time, document a start and stop or the total time, and you must furnish the full time. The midpoint rule does not apply. Medical necessity is why Medicare pays. A higher level is not appropriate when a lower level fits the visit (MLN006764).

Read the K.L. lines in that order. They show what you addressed, what you reviewed, and the decision you made. They do not pick the code by themselves.

• Problems: name the illness you addressed today, including a side effect of treatment if you addressed it. A problem list you did not touch does not belong on this line.
• Data: name each score, note, result, or discussion you actually used. One score is one item. Do not write “data reviewed” as if the score carried the level.
• Risk: write the prescription decision and what you weighed. A medication list, without the decision, does not show management.
• Your payer, the rest of the chart, and the path you chose (decision making or time) still sit between these lines and the claim.

If you select by time, the established-patient minute bands live on the 99214 guide. Put the minutes on the note. Do not borrow a band from memory and leave the clock blank.

A decision to continue is enough for the risk line when you weighed something. “Continue current meds” with no interval, no adherence count, and no side-effect ask is the line I send back. You did not show management. You showed a habit.

If cost, housing, or another social factor limited the fill or the follow-up, write that limit on the risk line. Write it only when it is true for this person. Do not add it to make the visit look harder.

If the visit also includes a therapy move

Name the move in its own block when you used one. A CBT cue for the missed doses, an ACT willingness rep about the side effect, or an IFS check that a part is blocking the morning pill: write the framework, the move, and the response. “Supportive” does not tell the next clinician which framework you used.

Keep that block out of the medication-changes line. The dose decision should be readable in one pass. If you will report psychotherapy as a separate service on the same day, the 99214 guide and the modifier 25 note are where the two services are split on the claim. On this note, the split is simpler: the medication decision has its own section, and the therapy move has its own sentences.

I do not fold a thought record into the dose line to make the visit look longer. If the only therapy was the cue K.L. chose (pill next to the coffee maker), that cue belongs in follow-up. It is not a second service, and it is not a reason to raise the level.

Copy the blank lines

If the hour needs cluster prompts for the exam itself, use the mental status exam cheat sheet. Do not reprint a normal exam you did not perform.

What stays in the medical record

Medication prescription and monitoring belong in this chart note. 45 C.F.R. § 164.501 excludes medication prescription and monitoring from psychotherapy notes, along with 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. Those items stay in the medical record.

Your hypothesis about why the morning dose gets skipped, and your countertransference when they shrug at the side effect, do not belong on this page if you keep a separated psychotherapy note. The decision, the count of missed doses, and the exam do.

If you do not prescribe

Leave the dose line blank of any titration you did not make. Write the side effect they named, the adherence count they gave you, the risk you asked, and the coordination you started. “Discussed meds” is not coordination. Name who you contacted and what you asked them to decide.

When the hour was therapy and the medication question was a mention, switch to the patient-note skeleton. Do not force eight medication sections onto a visit that did not turn on a prescription.

Before you sign

Open last month’s psychiatry notes only to see the last dose. Read four lines and stop if any one is a copy from last month.

1. Did you ask what changed, or did you reuse the old interval?
2. Did you count missed doses, or write “adherent”?
3. Did you ask about the side effect you would expect from this drug?
4. Can a covering clinician see the decision, the reason, and the return date without calling you?

If a scribe drafted the interval, you still write the medication decision, and you still sign. The tool question sits on the AI scribe for psychiatry comparison. The chart question is the twelve lines above. If you want a draft of those lines to edit before you sign, AI clinical notes can start the skeleton. You still cut anything you did not do.

Download the note skeletons

The PDF holds a format-neutral patient note on page one and these psychiatry notes on page two. Fill one page. Sign it. Do not mix a therapy hour and a medication visit onto one sheet.

References

• Centers for Medicare & Medicaid Services. (2026). Evaluation and management services (MLN006764). https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf
• Centers for Medicare & Medicaid Services. (2026). Medicare National Correct Coding Initiative policy manual, Chapter XI. https://www.cms.gov/files/document/11-chapter11a-ncci-medicare-policy-manual-2026-final.pdf
• Code of Federal Regulations. (2025). Definitions, 45 C.F.R. § 164.501. https://www.govinfo.gov/content/pkg/CFR-2025-title45-vol2/pdf/CFR-2025-title45-vol2-sec164-501.pdf