Top 10 Clinical Note Templates Used by Psychiatrists in 2025

Which Templates Streamline Documentation Across Psychiatric Care Settings?

Psychiatric clinicians address a wide array of patient presentations—from initial diagnostic assessments and medication management to psychotherapy sessions and crisis interventions. To maintain efficiency, accuracy, and therapeutic engagement, leading psychiatric practices in 2025 rely on a core set of structured note templates. These templates reduce charting time by up to 60%, ensure DSM-5 adherence, and support comprehensive coding for value-based mental health care models.

 

 

 

Rank	Template Name	Usage Frequency	Key Features
1	Psychiatry SOAP Note	Daily (90%)	Subjective: chief complaints, PHQ-9/GAD-7 scores, psychosocial stressors Objective: mental status exam (MSE) fields Assessment: DSM-5 diagnoses with specifiers Plan: medication changes, psychotherapy goals, safety planning prompts
2	Mental Health Progress Note	Daily (80%)	Symptom rating scale trends, medication adherence logs, risk assessment updates (suicide, violence), functional status tracking
3	Psychiatric Initial Assessment	Weekly (70%)	Comprehensive biopsychosocial history sections, family psychiatric history, trauma inventory, substance use assessment, baseline rating scales (PHQ-9, PCL-5, ADHD scales)
4	Mental Status Exam Template	Daily (75%)	Standardized fields for appearance, behavior, speech, mood/affect, thought process, cognition, insight, judgment; severity scales for psychotic or mood symptoms
5	Psychotherapy Session Note	Daily (85%)	Therapy modality (CBT, DBT, psychodynamic), session objectives, interventions applied, patient response, homework assignments, next session goals
6	Medication Management Note	Weekly (60%)	Current medication list, side-effect checklist, efficacy rating, lab monitoring prompts (lithium levels, metabolic labs), adherence interventions
7	Crisis Intervention Note	As needed	Safety assessment (suicidality/homicidality), crisis de-escalation interventions, involuntary hold criteria, discharge disposition, community resource referrals
8	Psychiatric Consultation Note	Weekly (50%)	Referral question, summary of findings, consult recommendations, liaison communication fields for multidisciplinary teams
9	Risk Assessment Note	Weekly (65%)	Structured suicidality and self-harm ideation scales (C-SSRS), protective factors, alert level indicators, mandatory reporting prompts
10	Psychiatric Discharge Summary	Monthly (30%)	Hospital course summary, discharge medications, outpatient follow-up plan, community supports, relapse prevention plan

 

 

 

1. Psychiatry SOAP Note

The SOAP format underpins 90% of daily psychiatric encounters.

• Subjective: Embeds standardized screening tools—PHQ-9 for depression, GAD-7 for anxiety—and prompts for psychosocial stressors (employment, relationships).
• Objective: Captures discrete MSE fields via dropdowns for rapid entry.
• Assessment: Lists DSM-5 diagnoses with specifiers (severity, chronicity).
• Plan: Auto-populates medication titration options, psychotherapy goals, and safety-planning modules (lethal means reduction, crisis contacts).

 

2. Mental Health Progress Note

Progress notes document ongoing treatment and symptom changes in 80% of follow-up visits.

• Tracks rating scale scores over time in a graphical trends section.
• Includes medication adherence logs and side-effect checklists.
• Prompts updated risk assessments, documenting any new suicidality or violence ideation.
• Functional status fields capture work, school, and social engagement levels.

 

3. Psychiatric Initial Assessment

Used for 70% of intake evaluations, ensuring a comprehensive baseline.

• Collects detailed biopsychosocial history, including trauma inventories and family psychiatric history.
• Substance use modules prompt standardized screening (AUDIT-C, DAST-10).
• Embeds baseline symptom scales—PHQ-9, PCL-5 for PTSD, ASRS for ADHD—facilitating precise diagnosis and treatment planning.
• Collateral information fields support input from family or other providers.

 

4. Mental Status Exam Template

Standardized MSE templates streamline documentation in 75% of sessions.

• Discrete fields for appearance, behavior, speech, mood/affect, thought content/process, cognition, insight, and judgment.
• Severity sliders for psychosis, suicidality, and agitation.
• Automated red-flag alerts for disorganized thought or severe cognitive impairment prompting urgent intervention.

 

5. Psychotherapy Session Note

Applies to 85% of psychotherapy visits across modalities (CBT, DBT, psychodynamic).

• Records session objectives and specific interventions used (exposure exercises, cognitive restructuring).
• Documents patient response and homework assignments.
• Next-session goal fields support ongoing treatment planning and progress tracking.

 

6. Medication Management Note

Used weekly in 60% of pharmacotherapy visits.

• Lists current psychotropic medications with dosage and adherence ratings.
• Side-effect checklist based on standardized scales (UKU side-effect rating scale).
• Lab monitoring prompts for medications requiring levels (lithium, valproate) and metabolic monitoring for antipsychotics.
• Adherence intervention options (pillboxes, long-acting injectables).

 

7. Crisis Intervention Note

Essential for emergency and crisis settings, used as needed.

• Embeds C-SSRS for suicidality and homicide risk.
• Documents immediate de-escalation interventions (verbal de-escalation, safety seating).
• Supports involuntary hold criteria fields and legal documentation prompts.
• Discharge disposition section for transfer to higher level of care or community resources.

 

8. Psychiatric Consultation Note

Utilized in 50% of consult-liaison psychiatry encounters.

• Starts with referral question and summary of primary team findings.
• Comprehensive MSE and mental health history sections.
• Clearly outlines consult recommendations—psychopharmacology adjustments, capacity evaluations—and communicates plans to referring teams.

 

9. Risk Assessment Note

Implemented in 65% of follow-up visits or as indicated.

• Structured suicidality and self-harm ideation scales.
• Protective factor inventory and safety plan fields.
• Alert level indicator dashboard (green/yellow/red) to guide follow-up frequency.
• Mandatory reporting prompt configurations for minors or vulnerable adults.

 

10. Psychiatric Discharge Summary

Produced for 30% of inpatient and residential discharges.

• Summarizes hospital course, critical incidents, and treatment response.
• Lists discharge medications with dosage and monitoring instructions.
• Outpatient follow-up plan schedules and community support contacts.
• Relapse prevention plan including coping strategies and crisis contacts.

 

Clinical Insight & Best Practices

• Integrate DSM-5 Criteria Prompts: Embedding diagnostic criteria checklists ensures accurate, defensible diagnoses.
• Automate Safety Planning: Crisis and risk templates should auto-generate safety plan handouts with patient and clinician signatures.
• Balance Detail and Usability: Avoid overly lengthy templates; focus on high-value fields to maintain clinician efficiency.
• Leverage Analytics: Use practice dashboards to monitor template usage, identify under-used critical sections, and optimize based on clinician feedback.

 

Next-Step Engagement

– Explore how AI-powered scribe platforms can auto-populate these psychiatric templates from clinician-patient conversations.
– Consider implementing S10.AI to improve documentation accuracy, ensure comprehensive risk assessments, and reclaim clinician time.
– Learn more about standardized template design and continuous quality improvement through APA and AAPC resources.