A psychiatric progress note records a follow-up or medication management visit: what changed, how the treatment is working, and what you decided. Copy the free template, see two filled examples, and check what each part needs, from side effects to the reason for a dose change.
Blank psychiatric progress note template
FreePSYCHIATRIC PROGRESS NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Visit type: [In person, video, or phone; follow-up or medication management] Clinician: [Name, credentials] Diagnoses being treated: [Working diagnoses] INTERVAL HISTORY Since the last visit: [Weeks since the last visit, events, stressors, changes at work, school, or home] Patient's report: [How the patient says things are going, in their words] Collateral: [Family, therapist, or pharmacy information, if any] TARGET SYMPTOMS Mood and anxiety: [Better, same, or worse, with examples] Sleep and energy: [Hours, quality, daytime energy] Appetite and weight: [Changes since the last visit] Other targets: [Attention, psychosis, panic, obsessions, or other symptoms being treated] New symptoms: [Including any sign of mania, agitation, or psychosis] Functioning: [Work, school, relationships, self-care] MEDICATIONS Current regimen: [Each psychiatric medication with dose and timing] Adherence: [Missed doses, how they are taken, refill history] Side effects: [Asked about, present or absent, and how bothersome] Other medications and substances: [New prescriptions, over-the-counter, supplements, alcohol, cannabis, caffeine] MEASURES AND MONITORING Rating scales: [Such as PHQ-9 or GAD-7, today and at the last visit] Vital signs: [BP, HR, weight, BMI, as the medication requires] Labs: [Drug levels with time since the last dose, metabolic labs, ECG, with dates] Prescription monitoring: [Database checked, for controlled medications] MENTAL STATUS EXAM Brief MSE: [Appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight, judgment] RISK SCREEN Suicide and self-harm: [Thoughts, intent, plan, or behavior since the last visit] Harm to others: [Thoughts or behavior] Change in risk: [Higher, lower, or unchanged, and why] ASSESSMENT Response: [Remission, response, partial response, or no response, for each diagnosis] Reasoning: [What explains the change or lack of change: dose, duration, adherence, side effects, stressors] PLAN Medication changes: [Start, stop, increase, decrease, or continue, with dose and rationale] Consent and education: [Risks, benefits, and alternatives discussed; the patient's agreement] Monitoring due: [Labs, vital signs, and scales to repeat, and when] Therapy and coordination: [Psychotherapy, primary care, other providers] Safety: [Safety plan reviewed, and when to seek urgent help] Follow-up: [Interval, and when to return sooner] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient psychiatry, 8-week medication follow-up
41-year-old man, 8 weeks after starting sertraline for a first episode of major depression. Back at work full time for 3 weeks. CBT every 2 weeks. No new stressors. “I’m about halfway back to normal. Evenings are still hard.”
Mood: better most days, still low in the evenings. Interest: has restarted cycling once a week. Sleep: 6 to 7 hours, no more early waking. Energy and concentration: improved, but tires by mid-afternoon. Appetite normal. No elevated mood, less need for sleep, or racing thoughts.
Sertraline 50 mg every morning. Missed 1 dose in 4 weeks; uses a pill organizer. Nausea in week 1, now gone. Mild decrease in libido, not bothersome to him. No restlessness, sweating, or headaches. No other medications or supplements. Alcohol 2 drinks a week; no cannabis.
PHQ-9 12 today; 18 at baseline, 14 at week 4. GAD-7 6. BP 124/78, HR 72, weight 82 kg (181 lb), unchanged. No labs needed.
Neatly dressed, calm, good eye contact. Normal speech. Mood “better, not there yet.” Affect mildly restricted, brighter than last visit, reactive. Linear thought process. No suicidal or homicidal ideation, no psychotic symptoms. Alert and oriented. Insight and judgment good.
No suicidal thoughts or self-harm since the last visit; the passive thoughts reported at baseline have resolved. No thoughts of harming others. No firearms at home. Risk lower than at baseline: low.
Major depressive disorder, single episode, moderate: partial response to sertraline 50 mg at 8 weeks, with the PHQ-9 down by a third. Good adherence and tolerance, so the dose is the likely limit. No signs of bipolar disorder.
Increase sertraline to 100 mg every morning, for partial response at 8 weeks on the starting dose with good tolerance. Nausea may return for a few days. Continue CBT. Repeat PHQ-9 and GAD-7 at the next visit. Contact the clinic for worsening mood, agitation, or new suicidal thoughts; in an emergency, call 911 or go to the nearest emergency department. Video follow-up in 4 weeks.
Outpatient psychiatry, 6-week medication follow-up
29-year-old woman with ADHD, combined presentation, diagnosed 3 months ago. Six weeks on methylphenidate extended-release 36 mg every morning. Finishing work tasks on time; her manager has noticed. On weekends she sometimes takes the dose late, around 11 a.m. “I can finally get through my list.”
Attention: holds through most of the workday, fades after about 4 p.m. Organization: uses a planner daily. Impulsivity: interrupts less in meetings. Mood steady; no new anxiety. Sleep: asleep by 11:30 p.m. most nights, but after 1 a.m. when the dose is late. Appetite: little interest in lunch, large dinner.
Methylphenidate extended-release 36 mg every morning; skips some weekend doses by choice. Side effects: lower appetite at midday, dry mouth, later sleep after late doses. No palpitations, chest pain, fainting, headaches, tics, or low mood. Stores it securely and doesn’t share it. Caffeine 2 coffees a day. No cannabis or other drugs.
ASRS symptom checklist 30, down from 51 at baseline. BP 126/80, HR 84; at baseline 118/76 and 72. Weight 59 kg (130 lb), down 1.5 kg (3 lb) from baseline. Prescription monitoring database checked: no other controlled prescriptions.
Well groomed, calm, sits still through the visit. Normal speech. Mood “good, more on top of things.” Affect full and reactive. Linear, focused thought process. No suicidal or homicidal ideation, no psychotic symptoms. Insight and judgment good.
No suicidal or self-harm thoughts. No thoughts of harming others. No signs of misuse or diversion: takes it as prescribed, no early refill requests. Risk unchanged: low.
ADHD, combined presentation: good response to methylphenidate extended-release 36 mg. Side effects are mild and tied to timing: late doses delay sleep, and midday appetite is lower, with a small weight loss. Small rises in BP and HR, within an acceptable range, to watch.
Continue methylphenidate extended-release 36 mg, taken by 8 a.m., on weekends too if she uses it. Eat breakfast before the dose and plan an afternoon snack. Recheck BP, HR, and weight at the next visit. Contact the clinic for palpitations; go to the nearest emergency department for chest pain or fainting. 30-day prescription. Follow-up in 6 weeks.
The symptoms the treatment is meant to change, tracked the same way at every visit so the trend shows.
Avoid: “Doing well” without saying which symptoms improved, or by how much.
What the patient actually takes, how, and with what effects.
Avoid: Carrying the medication list forward without checking it with the patient.
The numbers that show progress or flag harm.
Avoid: A lithium level with no timing. It should be drawn about 12 hours after the last dose, so record when it was.
A short safety check at every visit, and a fuller assessment when anything has changed.
Avoid: Repeating “no SI or HI” from the last note. Ask each time, and record what changed.
How each condition is responding to treatment, and why.
Avoid: Changing a medication without saying why the current plan isn’t enough.
The decision and the reasoning, so the next prescriber can follow it.
Avoid: A dose change with no follow-up date or monitoring plan.
Write why: partial response at an adequate dose and duration, a side effect, or a new symptom. The next prescriber needs the reasoning, not just the new number.
A PHQ-9 or GAD-7 means more beside the last one. Record today’s score with the baseline or previous score, so the trend is clear at a glance.
Patients rarely volunteer sexual side effects, weight gain, or restlessness. Ask, and record the negatives that matter for each medication.
Lithium levels, kidney and thyroid tests, metabolic labs on antipsychotics, and blood pressure on stimulants each have a schedule. Record the result and when the next check is due.
Ask about suicidal thoughts at each visit, and reassess fully after a loss, a hospital discharge, new substance use, or a medication change.
Vero Scribe writes the progress note in your template from the visit conversation, with the patient’s consent, or from your dictation. You check the doses, scores, and plan, edit anything, and copy the note into your EHR or export it to PDF or Word.
The interval history, target symptoms, medications with adherence and side effects, rating scales and monitoring, a brief mental status exam, a risk screen, your assessment of the response, and the plan with the reason for any change.
A progress note for a visit focused on psychiatric medication: whether it is working, side effects, monitoring, and any change in dose. This template is built for that visit.
Ones that match the target symptoms, used the same way at each visit: often the PHQ-9 for depression and the GAD-7 for anxiety, with other scales for ADHD, mania, or psychosis where they fit. Record today’s score beside the last one.
A brief MSE that touches each domain is usually enough. Expand it when something has changed, such as new psychotic symptoms, agitation, or a change in cognition.
Yes. Note that the visit was by video or phone and where the patient was, label home blood pressure and weight readings as patient-reported, and plan in-person checks when a medication needs measured vital signs.
Yes. Copy it, or download it as a Word or text file. No account needed.
The full first psychiatric assessment, with a structured mental status exam and a risk formulation.
An eight-step workflow, short examples, and a quality checklist.
Psychiatric visit notes, patient context, and follow-up in one workspace.
How Vero drafts progress notes in your template from the visit.
The codes used most often in psychiatry.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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