Psychiatrist Note Template

Take concise, comprehensive psychiatric notes using our pre-formatted and structured psychiatrist note template.

By Telita Montales on Jul 05, 2024.

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Fact Checked by Nate Lacson.

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Psychiatrist Note Template PDF Example
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What Is A Psychiatrist Notes Template

Psychiatrists need to take all kinds of notes throughout the day to meet their medical documentation requirements. Changes to medication, progress notes, incident notes, and any other significant updates must be documented and stored in the patient’s medical record, or electronic health record (EHR).

Our template is a handy tool for psychiatrists to structure their clinical notes. A template is a sort of skeleton format for your notes and includes headings, tables, and empty spaces for your patient’s information, medication regime, and any type of note you wish to write.

This template includes features specially designed to make psychiatrists’ lives easier, including a medication regime section, sub-headings for changes to medication, and referral/follow-up.

How To Use This Template For Psychiatrist Notes

Just follow these simple steps to start using our psychiatrist note template.

Step 1. Patient Information

The first section of our template is designed to help ensure you include your patient’s name, date of birth, optional identifier, and date and time of your session.

Step 2. Medication Review

The medication table is designed to visually separate the information related to your patient’s current medication regime from the rest of the note. This is helpful if you need to quickly find the medications your patient is currently using, and the table format makes it easy to see the dosage, frequency, indication, and any other notes you have on the medication.

Step 3. Psychiatrist Note

This section is designed for you to complete in your preferred note-taking style. Add in headings or sub-headings as you like, or write a free-form narrative note in this space instead. It’s up to you!

Step 4. Changes to medication and Referral/Follow up

These last two sections are designed to ensure the next steps for your patient, as determined from the evidence included in the psychiatrist note, are clearly visible within the note template.

Step 5. Sign and date the note

The last step is to sign and date the psychiatric progress note and store it in a HIPAA-compliant way to ensure the security of your patient’s sensitive medical information.

Psychiatrist Note Example (Sample)

Sometimes the quickest way to understand how to use something is to see a completed example. If that’s how you like to learn, we’ve got you covered too! Take a look at our example psychiatrist note. This resource uses our free psychiatrist note template and demonstrates what this template might look like once it is completed. Have a read below,

Download this Psychiatrist Note Example (Sample) here: 

Psychiatrist Note Example (Sample)

Who Can Use these Printable Psychiatrist Note Templates?

Our psychiatrist note template is designed for psychiatric professionals to use in any of their daily note-taking tasks. While this template was created with psychiatrists in mind, it can be used by any mental health professional with the ability to prescribe psychiatric medication. This could be:

  • Psychiatrists and psychiatric residents or trainees
  • Nurse practitioners and psychiatric nurse specialists
  • Physicians with psychiatric specialties.

Additionally, this template is simple enough to be used by psychiatrists of any specialty, including

  • Addiction psychiatrists
  • Adult psychiatrists
  • Child and adolescent psychiatrists
  • Forensic psychiatrists,

And many others!

Why Is This Template Useful For Psychiatrists

  • Save time: This template is designed to save you time, as well as optimize the note-taking process. Note-taking can be a time-consuming business, as every patient seen will have made different progress, be on different medication regimes, and have different plans for their next steps. All of these situations need to be documented in the patient’s medical records, so having one template to use for each note will save a lot of time!
  • Share your notes easily: keeping your notes digital, as well as having a standard template for your notes, will ensure if you ever need to share notes with other members of your patient’s care team, they will be able to understand your note quickly and easily.
  • Improve organization: using templates in your note-taking process is a great way to improve the overall organization of your practice’s administration. You won’t need to think about what format you want to use, just reach for your template and start writing.
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Benefits of Psychiatrist Notes 

Having a template for your psychiatry notes can provide your practice with many benefits and here are just a few.

Go paperless

Using our psychiatrist note template will allow you to keep your patient’s important medical records fully digital. This alone has huge advantages for your practice regarding information security, legibility, time management, and accessibility of patient data.

Streamline your note taking

Having a template for your notes is a great way to standardize your note-taking procedures, and ensure you are providing each patient with the same starting point for their progress notes. This will in turn ensure you are providing a similar level of care for all your patients and help to streamline your practice.

One template- many types of notes

We have kept this template simple enough for you to take notes in whichever style you prefer. Whether this is the commonly used SOAP format, a narrative note, a focus-based note, or another style entirely- our template can facilitate your note-taking needs.

Pre-made medication regime table

We have included a medication table in this template so you can clearly set out the objective information on your patient’s medication regime from the rest of your session or progress notes. You can save time formatting your notes and get back to treating your patients. 

Meet your legal obligations

Insurance companies, audits, or legal situations may require you to provide proof of your clinical decision-making. Our psychiatrist note template serves as great evidence to provide to third parties as it is clearly laid out, easy to follow, not to mention has a simple and professional design.

Why Use Carepatron For Psychiatrist Notes?

Carepatron provides a state-of-the-art and intuitive solution for psychiatric practice management. You can access patient information, complete your clinical documentation and store your patients’ notes all from our mobile or desktop platform. Using Carepatron for psychiatric notes also minimizes the time you spend transferring information between different systems, as everything you need is securely stored in one place. 

Carepatron provides a HIPAA-compliant solution for the storage of your patient's confidential information, and by keeping your medical documentation digital in Carepatron’s simple-to-use platform, you can ensure your data will be secure and accessible when you need it.

In addition to bank-level security encryption, Carepatron also offers all the high-tech features your practice needs to stand out from the crowd. These include a client portal for your patients, AI-powered dictation software, billing, and appointment scheduling tools, telehealth conference capabilities, and a library of handy community templates like this one.

Psychiatrist Note Software
What is a psychiatrist note?
What is a psychiatrist note?

Commonly asked questions

What is a psychiatrist note?

A psychiatrist's note is a form of clinical documentation completed by psychiatrists to document important information on their patients. There are many different types of notes, such as progress notes, session notes, incident notes, procedure notes, therapy notes, and many others. Our psychiatrist note template is designed to be broad enough for concise forms of any of these types of notes while ensuring there is still space for important information such as the patient’s medication regime, changes recommended, and information on the patient’s follow-up.

Are patients allowed to see their pyschiatrist’s notes?

Patients have the right to request a copy of anything in their medical record, including psychiatrist notes that have been entered into their record. This means it’s important to ensure your notes do not include any irrelevant or overly judgmental comments about your patients.

What should a psychiatrist note include?

This will depend on the psychiatrist, and the type of note they are writing. The note should include the patient’s identifying information to ensure it is assigned to the correct patient, along with a concise summary of the patient’s updates. The note may also include the patient’s medication regime, changes to their medication, and the next steps for the patient’s treatment.

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