Comprehensive Mental Health Evaluation Note Template for Psychiatrists

Sample Psychiatry Custom AI Note Template

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Custom Note Instructions


Structure: Notes follow a structured format with clear section headers, beginning with the Chief Complaint and ending with the Treatment Plan.

Clarity and Conciseness: Documentation is detailed yet concise, with bullet points used in medication and treatment plans for readability.
Comprehensive Assessment: Key domains like psychosocial history, mental status examination, and risk assessment are thoroughly documented.

Use of Psychiatric Terminology: Incorporates standard psychiatric terminology (e.g., constricted affect, linear thought process, GAF score) for professional communication.

Risk Focus: Prioritizes risk assessment (suicide/homicide) with clear documentation of ideation, intent, and protective factors.

Diagnosis Framework: Uses a multi-axis diagnosis framework (Axis I-V) to provide a comprehensive evaluation.

Treatment Plan Clarity: Outlines specific and actionable treatment recommendations, including medication, therapy, and lifestyle interventions.

Custom Section Instructions


Chief Complaint:

Format: Directly quotes the patient’s primary concern for authenticity.
Focus: Brief but reflective of the patient's emotional state and key symptoms.

History of Present Illness:

Include: Onset, duration, severity, and context of symptoms.
Style: Narrative with a chronological flow, linking situational stressors to symptom development.
Avoid: Overloading with non-pertinent details; keep it focused on psychiatric relevance.
Format this section as a single, comprehensive paragraph, without any length restrictions, ensuring all pertinent information is included.

Past Psychiatric History:

Include: Diagnoses, treatments, hospitalizations, and therapy history.
Format: List previous interventions chronologically for clarity.

Substance Abuse History:

Format: Brief and categorical (current vs. past use; frequency).
Detail: Denials should also be explicitly stated for thoroughness.

Psychosocial History:

Focus: Living situation, employment, support systems, and stressors.
Style: Narrative with attention to relevant social determinants of mental health.

Mental Status Examination:

Format: Use structured subheadings (e.g., Appearance, Mood, Thought Process).
Style: Objective and descriptive, avoiding subjective interpretations.
Highlight: Risk-related observations (e.g., ideation, judgment).
  1. Appearance:
  2. Behavior:
  3. Demeanor/Manner:
  4. Speech:
  5. Mood:
  6. Affect:
  7. Thought Process:
  8. Thought Content:
  9. Orientation:
  10. Attention:
  11. Concentration:
  12. Memory:
  13. Fund of Knowledge:
  14. Insight:
  15. Judgment:
  16. Impulse Control:
  17. Abstraction:

Risk Assessment:

Suicide Risk:
Homicide Risk:
Access to Firearms:

Diagnosis:

Use: Multi-axis framework (Axis I-V) or current DSM format if preferred.
Include: Primary psychiatric diagnosis, medical comorbidities, and relevant psychosocial factors.

Treatment Plan:

Format: Numbered list for readability.
Include: Medication recommendations (with dosing), therapy referrals, lifestyle interventions, and follow-up plans.
Highlight: Actionable steps with timeframes for follow-up.