General Psychiatric Note Template

.gpnt

Patient Information
– Patient Name:

Patient Full Name

– Date of Birth: Month: 01/Day: 01/Year: 2001
– Date of Visit: Month: 01/Day: 01/Year: 2001
– Appointment Type:

Appointment Type: [New|Follow Up]

– Patient ID:

Unique Identifier

Chief Complaint
– Main Issue(s):

Brief statement of the primary concern or reason for the visit

History of Present Illness (HPI)
– Description of Symptoms:

Detailed description of symptoms and impact on patient

– Onset:

When the symptoms started

– Duration:

How long the symptoms have been occurring

– Severity:

Scale or description of severity

– Context:

Circumstances/setting in which symptoms occur

– Modifying Factors:

Anything that worsens/improves symptoms

– Associated Signs and Symptoms:

Any other symptoms noted

Past Psychiatric History
– Previous Diagnoses:

List any past psychiatric diagnoses

– Hospitalizations:

History of any psychiatric hospitalizations

– Treatments and Responses:

Prior psychiatric medications and therapies, and responses to them

Substance Use History
– Alcohol:

Usage and frequency

– Drugs:

Type, usage, and frequency

Family Psychiatric History
– Family Disorders:

Any psychiatric disorders in the family

– Family Dynamics:

Brief description of family structure and relationships

Social History
– Living Situation:

With whom the patient lives and the nature of the home environment

– Occupational History:

Current employment status and job, or past employment if relevant

– Educational Background:

Highest level of education achieved

– Legal Issues:

Any relevant legal issues or history

– Support System:

Description of support network

Mental Status Examination (MSE)
– Appearance:

Observations of patient’s physical appearance and behavior

– Attitude:

Cooperative, hostile, etc.

– Behavior:

Any unusual movements, activity level

– Speech:

Rate, volume, articulation

– Mood and Affect:

Patient’s reported mood and observed affect

– Thought Process:

Rate, continuity, coherence of thought

– Thought Content:

Presence of delusions, hallucinations, etc.

– Cognition:

Orientation, attention, memory, general knowledge, abstract thinking

– Insight:

Understanding of one’s own condition

– Judgment:

Ability to make reasoned decisions

Assessment
– Diagnostic Impression:

Clinical diagnoses based on DSM criteria

– Risk Assessment:

Risk of harm to self or others

Plan
– Medication:

Any changes to medication, dosages, or regimen

– Psychotherapy:

Type and frequency of therapy planned

– Orders and Referrals:

Any orders for labs, imaging, or referrals to other providers

– Follow-Up:

Timing and focus for the next appointment

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