Psychiatric Progress Note Template
- kbuch88
- Aug 19
- 4 min read
What Is a Psychiatric Progress Note Template?
Psychiatric treatment requires documentation that is thorough, coherent, and clinically structured. A psychiatric progress note template provides a consistent framework for capturing the essential elements of follow-up encounters—tracking symptom changes, medication response, risk assessments, diagnostic impressions, and treatment plans.
Rather than improvising each note from scratch, the template allows clinicians to organize clinical information in a way that aligns with standard psychiatric workflows, supports billing requirements, and enhances continuity of care.
When Should You Use a Psychiatric Progress Note Template?
The progress note template is best utilized when:
Conducting a routine psychiatric follow-up
Evaluating medication response or side effects
Tracking clinical progress or symptom relapse
Performing a risk assessment
Assigning or updating DSM-5-TR diagnoses
Generating notes for billing or audits
This structure is relevant in outpatient psychiatry, primary care with a behavioral focus, consult-liaison psychiatry, and telepsychiatry contexts.
How Should You Use a Psychiatric Progress Note Template?
The template is designed to streamline documentation while ensuring that all key elements are captured. It provides an architecture for:
Visit context (Summary, Chief Complaint)
Narrative history (HPI)
Interventions (Medications, Medication Access)
Status updates (Sleep, Tests, Mental Status Exam)
Clinical reasoning (Assessment, DSM-5-TR Codes)
Safety planning (Safety Assessment)
Next steps (Plan, Follow-Up, Billing, To-Dos)
The purpose is to reduce the burden of note-writing and allow you to focus on clinical decision-making.
Key Sections of the Progress Note Template
Summary & Chief Complaint
Summary: High-level synopsis of the clinical status and reason for evaluation.
Chief Complaint: The patient's stated reason for follow-up.
Clinician Tip
If the summary and chief complaint diverge, highlight that discrepancy—it often signals clinical significance.
History of Present Illness (HPI)
This is your running narrative. It captures symptom changes, medication effectiveness, functional status, and psychosocial stressors. The narrative should answer: What has changed since the last visit?
Clinician Tip
Be specific. “Feeling better” means little without detail. Include behavior, cognition, affect, and functioning.
Medications & Medication Access
Document medications prescribed, adjusted, or discontinued
Note side effects, adherence, and access issues
Clinician Tip
If a medication is not taken due to cost, insurance, or pharmacy errors, document it—this is clinical context, not administrative noise.
Tests and Scores
Quantitative measures (e.g. PHQ-9, GAD-7, MOCA)
If you’re not using quantitative tools, note behavioral anchors (e.g. “tearful throughout session,” “slow psychomotor tempo”)
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
This is your clinical synthesis. Summarize:
Symptom evolution
Functional capacity
Medication efficacy or issues
Stressors and supports
Diagnostic justification
Safety Assessment
Include details about:
Suicidal ideation (passive vs. active, plan, means, intent)
Homicidal ideation
History of attempts or self-harm
Access to lethal means
Protective factors (family support, insight, future orientation)
DSM-5-TR Diagnosis Codes
Include:
Diagnostic name
ICD-10 code
Rationale for changes if diagnosis is updated
Example
Major Depressive Disorder, Recurrent, Moderate (F33.1) Symptoms have persisted for >2 weeks, with anhedonia, insomnia, and psychomotor retardation. Functional impairment in work and social settings.
Plan
Here’s where you put down actionable next steps. This should include:
Medication changes
Lab orders or screening
Referrals (e.g. therapy, group, case management)
Safety planning
Behavioral goals
Psychoeducation delivered
Follow-Up & To-Dos
Recommended return interval
Tasks assigned to clinician (e.g. prior authorizationss, collateral gathering)
Tasks assigned to patient
Billing Codes
Insert applicable CPT and ICD codes based on the content of the note. JotPsych’s AI helps surface appropriate codes automatically.
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 Psychiatric Progress Note Template
What It Is
JotPsych provides an AI-integrated progress note designed specifically for psychiatric use. It includes fields for all major components: Summary, Chief Complaint, HPI, MSE, Risk, DSM-5 diagnoses, and Plan.
How It Works
Before a patient encounter, you open JotPsych, select your psychiatric progress note 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 below.
Why Use JotPsych for Progress Notes?
Full capture of psychiatric documentation
AI automatically sorts data into structured sections
Risk, diagnosis, and plan tracking is built-in
DSM-5 codes and billing fields included
Saves time—no manual transcription or typing required
Customizing the Template
Prefer a different format? Add or remove sections, change order, or rename fields. Your custom structure will be preserved in future notes. To learn how to customize, click 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.
What makes this template specific to psychiatry?
DSM-5 diagnosis support
Safety assessment fields embedded
MSE prestructured
Includes clinical, administrative, and compliance-relevant data