E/M & Psychotherapy Template

What Is an E/M + Add-On Psychotherapy Template?

Psychiatric care often requires a dual focus: medication management and psychotherapy. This template is purpose-built for sessions that include both. It allows you to track psychiatric symptoms, adjust treatment plans, and simultaneously document the therapeutic techniques and content of the session—whether you’re doing CBT, motivational work, psychoeducation, or supportive therapy.

With distinct sections for psychopharmacologic management and psychotherapy interventions, the template keeps both domains cleanly separated and billable.

When Should You Use an E/M + Psychotherapy Template?

Use this template when:

• You are providing medication management alongside psychotherapy
• The visit includes both symptom monitoring and active therapeutic intervention
• You’re delivering evidence-based therapies (CBT, DBT, IPT, etc.)
• You want to clearly support CPT billing for combined E/M + therapy sessions

It’s a fit for outpatient psychiatry, integrated behavioral health settings, and psychiatric nurse practitioner clinics where psychotherapy is part of the workflow.

How Should You Use This Template?

This template captures both the medical and therapeutic elements of the session in structured form.

It includes:

• Summary / CC → Why the patient came in
• HPI → Clinical narrative with symptom tracking and treatment response
• ROS → Targeted symptom domains
• Mental Status Exam → Objective psychiatric findings
• Assessment & Plan → A single narrative that synthesizes symptoms, medication changes, goals, and next steps
• Add-On Psychotherapy → Specific interventions, patient responses, and time spent

Clinician Tip

Distinguishing the psychotherapy section from general assessment is important for documentation and reimbursement. You’re not just “talking with the patient”—you’re intervening with structure and purpose.

Key Sections of the E/M + Psychotherapy Template

Summary & Chief Complaint

• Summary: High-level synopsis of the clinical status and reason for evaluation.
• Chief Complaint: Patient’s own words for the session focus—may reflect meds, mood, therapy goals, or all three.

HPI (History of Present Illness)

This is your running narrative. Document:

• Mood, anxiety, sleep, or psychosis symptoms
• Functional status
• Medication adherence and side effects
• Behavioral changes or stressors

Clinician Tip

Include subjective content and objective judgment—what the patient reports and your interpretation.

Review of Systems (ROS)

Targeted symptom review in relevant domains. Common psych ROS includes:

• Depression (e.g. low mood, anhedonia, SI)
• Anxiety (e.g. GAD, panic, phobias)
• Mania, psychosis, PTSD, OCD, eating, attention symptoms

Clinician Tip:

Keep it focused—this is not a comprehensive med ROS, but a targeted psychiatric snapshot.

Mental Status Exam (MSE)

Standard components include:

• Appearance
• Behavior
• Speech
• Mood / Affect
• Thought process / content
• Perceptions
• Cognition
• Insight / Judgment

Clinician Tip

Use WNL when appropriate, but document abnormalities clearly and specifically.

Assessment & Plan (Narrative)

This is the synthesis. Tie together:

• Current symptom status
• Medication efficacy or issues
• Functional impact
• Diagnostic impressions (you can include DSM-5 here if useful)
• Planned changes (meds, labs, referrals)
• Safety issues
• Therapy goals

Clinician Tip

Write this like you’re explaining it to another clinician taking over care. Be precise about what’s working, what’s not, and why.

Add-On Psychotherapy

This section documents the therapeutic portion of the session.

Make sure to include:

• Type of therapy: CBT, supportive, motivational, psychoeducation, etc.
• Techniques used: Cognitive restructuring, behavioral activation, exposure, affect labeling, etc.
• Content of discussion: Specific topics addressed (e.g. trauma processing, grief, identity conflicts)
• Patient’s engagement: Receptive, resistant, avoidant, insightful
• Time spent: e.g. “Psychotherapy comprised 25 minutes of the 45-minute session.”

Example

Psychotherapy: 25 minutes of the 45-minute session focused on CBT for anxiety. The patient identified distorted thoughts regarding social judgment and practiced a thought record. Engagement was high; insight appeared to increase as session progressed.

What Is an AI Scribe?

An AI scribe is an automated tool to simplify the process of note-taking and documenting patient encounters. An AI scribe will automatically convert rough notes into a structured record of the intake, documenting the specifics and filling out a template for you. The goal is that you handle the ideas and encounter, and the AI tackles the procedure.

JotPsych’s E/M + Psychotherapy Template

What It Is

This JotPsych template is designed for dual-focus psych visits. It contains all core medical sections and a dedicated psychotherapy block, preformatted for accurate billing and narrative clarity.

How It Works

Before a patient encounter, you open JotPsych, select your E/M + Psychotherapy template, and begin recording. The template has every section you should need in your intake, but can be easily customized if you find your encounters taking a different shape. To see how to create your first note, click here, and to see how to customize a template, click here.

When your encounter concludes, simply finish recording in JotPsych. Our AI will autopopulate the template with the relevant parts of your discussion, turning the conversation into notes automatically.

To see what a sample encounter looks like and how JotPsych turns any recording into a comprehensive note, click here.

Benefits of the E/M + Psychotherapy Template

• Structured notes for combined visits
• Clear separation of medical vs. therapy domains
• Reduces time spent documenting therapeutic content
• Enhances billing accuracy with CPT support
• Captures nuanced therapeutic process, not just symptoms
• Fully customizable for your style of practice

Customizing the Template

Want to specify your therapy modalities, rename fields, or change section order? You can easily edit the template, and JotPsych will follow your customized version in future sessions. Learn how by clicking here.

FAQ

Is submitting recordings to JotPsych secure?

Yes, it is! JotPsych takes extensive measures to remain HIPAA compliant and uses secure encryption to maintain the integrity of patient data.

Why is this template different from a regular E/M note?

• It includes a dedicated psychotherapy section
• Supports CPT codes for combined E/M + therapy
• Structured to reflect both treatment modalities in one document
• Emphasizes intervention and engagement, not just symptoms

With this template, you don’t have to choose between writing a psych note or a therapy note—you get both. JotPsych captures the full scope of your session. You provide the care. The AI takes care of the rest.