PSYCHIATRIC 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]