Comprehensive Mental Health Evaluation Note Template for Psychiatrists
Sample Psychiatry Custom AI Note Template
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.
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