Psychiatric Progress Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm.

Assessment:
Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed.

Plan:
Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Psychiatric Note

Identifying Information:
[Patient name], [age], [gender], [relevant demographic details]

Chief Complaint:
[Patient’s own words or brief summary of presenting problem]

History of Present Illness:
[Chronological description of current symptoms, onset, duration, severity, precipitating factors, alleviating/aggravating factors, impact on functioning, previous episodes, treatments tried, response to treatment]

Past Psychiatric History:
(hyphenated list)
- [Previous psychiatric diagnoses]
- [Prior hospitalizations]
- [Past suicide attempts or self-harm]
- [Previous treatments and response]
- [History of psychotherapy]

Past Medical History:
(hyphenated list)
- [Medical diagnoses]
- [Surgeries]
- [Other relevant medical issues]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include psychiatric and non-psychiatric medications]

Allergies:
(hyphenated list)
- [Drug allergies and reactions]
- [Other allergies]

Family Psychiatric History:
(hyphenated list)
- [Family member: psychiatric diagnosis or relevant history]

Social History:
(hyphenated list)
- [Living situation]
- [Relationship status]
- [Children]
- [Employment/education]
- [Substance use: type, amount, frequency]
- [Legal history]
- [Cultural/spiritual background]

Mental Status Examination:
(hyphenated list)
- Appearance: [Description]
- Behavior: [Description]
- Speech: [Rate, volume, fluency]
- Mood: [Patient’s description]
- Affect: [Range, appropriateness]
- Thought process: [Coherence, organization]
- Thought content: [Delusions, obsessions, suicidal/homicidal ideation]
- Perceptions: [Hallucinations]
- Cognition: [Orientation, attention, memory]
- Insight: [Level of insight]
- Judgment: [Quality of judgment]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Relevant physical findings if performed]

Investigations:
(hyphenated list)
- [Lab results, imaging, other tests] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment:
[Summary statement including age, sex, and primary psychiatric diagnosis]
(hyphenated list)
- [Diagnosis and reasoning]
- [Differential diagnosis if applicable]
- [Risk assessment: suicide, homicide, self-harm, vulnerability]

Plan:
(hyphenated list)
- [Investigations planned or ordered]
- [Medication changes or recommendations]
- [Psychotherapy or counseling recommendations]
- [Safety planning]
- [Referrals to other providers]
- [Follow up plan]
- [Return precautions]