Intake structure
The initial evaluation is the one note that every later clinician reads. It has to answer three questions: what is going on, what has already been tried, and what is the risk. A consistent structure is what makes those answers findable in ninety seconds — by you at the next visit, by a covering colleague, or by an emergency department at 2 a.m.
| Section | What to capture |
|---|---|
| Chief complaint | The patient’s own words, in quotation marks, plus the referral source and reason |
| HPI | Onset, course, precipitants, current symptoms by domain, structured screens for mania, psychosis and trauma, function, treatment to date, the patient’s goals |
| Past psychiatric history | Prior diagnoses (by whom, when); hospitalizations with dates, reason, voluntary or involuntary status and length; suicide attempts and self-harm with method, medical severity and precipitant; violence and legal history; outpatient treatment |
| Medication trials | A table: drug, maximum dose, duration at that dose, response, side effects, reason stopped, dates — plus what has never been tried |
| Substance use | Each substance with amount, frequency, last use, withdrawal history and treatment; AUDIT-C or equivalent |
| Medical history | Conditions that mimic or complicate psychiatric illness (thyroid, seizure, TBI, sleep apnea, cardiac, hepatic and renal), non-psychiatric medications, allergies, pregnancy or lactation status, last labs |
| Family history | Psychiatric illness, suicide and substance use in first- and second-degree relatives; medication response in relatives |
| Social and developmental | Birth and development, adverse childhood experiences, education, employment, relationships, living situation, supports, legal, firearms access, military service, culture and spirituality |
| MSE | All ten domains, with cognition actually tested (MSE examples) |
| Risk assessment | SI/HI as separate facts, prior attempts, access to means, risk and protective factors, acute and chronic risk with rationale, safety plan |
| Screening | PHQ-9, GAD-7, and disorder-specific tools indicated by the HPI (MDQ, PCL-5, ASRS, Y-BOCS, AUDIT-C) |
| Formulation | Predisposing, precipitating, perpetuating and protective factors; the differential and why the leading diagnosis fits |
| Diagnoses and plan | DSM-5-TR diagnoses with ICD-10-CM codes; medications with rationale and informed consent; labs; therapy and referrals; safety; education; follow-up; code billed |
HPI template with prompts
The HPI is where most intake notes lose structure: it is either a transcript or a list of symptom words with no onset, course or function. The prompts below force the elements a diagnosis depends on — especially the mania and psychosis screens, which change the medication plan and are easy to skip when the presenting complaint is depression or anxiety.
HPI
[Age]-year-old [sex/gender] [referred by / self-referred] for evaluation of [chief complaint in patient's words].
Onset and course: symptoms began [when], [gradual / abrupt], [precipitant if any]; course since then [continuous / episodic / worsening]. Prior episodes: [number, duration, what resolved them].
Current symptoms (past 2 weeks): mood [ ]; interest/pleasure [ ]; sleep [onset / maintenance / early waking / hours]; appetite and weight [ ]; energy [ ]; concentration [ ]; psychomotor [ ]; guilt/worthlessness [ ]; hopelessness [ ].
Anxiety: [worry content, panic attacks with frequency, avoidance, physical symptoms].
Mania/hypomania screen: [decreased need for sleep, elevated/irritable mood ≥4 days, racing thoughts, pressured speech, increased activity, risky behavior — dates and duration if ever].
Psychosis screen: [AH/VH, paranoia, ideas of reference — ever].
Trauma: [exposure; intrusions, avoidance, hyperarousal, negative cognitions].
OCD / ADHD / eating / other: [pertinent positives and negatives].
Function: work/school [ ]; relationships [ ]; self-care [ ]; what the patient can no longer do [ ].
Treatment to date: [medications with response — see table]; [psychotherapy type, duration, benefit]; [what helped most].
Patient's goals for treatment: "[ ]".
Plain text, no formatting.
Medication-trial table
“Tried Zoloft, didn’t work” is not a medication trial. The questions that matter are the maximum dose, how long the patient stayed at it, what happened, and why it stopped — because an inadequate trial (two weeks at a starting dose) is a different fact from a failed one (eight weeks at a therapeutic dose), and the difference decides whether a drug is off the table. Record it as a table so it survives into every future note.
MEDICATION TRIALS
Drug | Max dose | Duration at max | Response (none / partial / full) | Side effects | Reason stopped | Dates
[ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ]
[ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ]
[ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ]
Never tried: [ ]. Adequate trials (≥6 wk at therapeutic dose): [ ]. Allergies/intolerances: [ ].
Plain text, no formatting.
Sample initial evaluation excerpt
A synthetic excerpt — HPI, the relevant history, and the formulation — for an adult referred for “treatment-resistant depression.” It is shown because it illustrates the most consequential intake question in outpatient psychiatry: unipolar or bipolar depression.
CC: “The antidepressants either do nothing or make me feel wired.”
HPI: 31-year-old self-referred after a third SSRI trial, for evaluation of recurrent depressive episodes. First episode at 19 during college (3 months, resolved without treatment). Second at 25 after a job loss (6 months; fluoxetine 20 mg for 10 weeks — no benefit). Current episode began about 4 months ago after a relationship ended: low mood most of the day, anhedonia, hypersomnia (10–11 h with daytime naps), increased appetite with 6 kg weight gain, leaden fatigue, poor concentration, and passive SI (“it would be easier not to be here”) without plan or intent. PHQ-9 today 18. Sertraline 50 → 100 mg for 6 weeks this episode: within 10 days of the increase, reported 3 nights of 4-hour sleep without fatigue, “talking faster than usual” per a friend, and starting two side projects; settled after the dose was reduced. On direct questioning, describes two prior periods (age 22, age 27) of about a week each with markedly decreased need for sleep, elevated mood, increased productivity and spending, not attributed to substances, noticed by others, without hospitalization or psychosis. Denies ever having AH/VH or paranoia. No panic attacks; some chronic worry. Denies trauma history. Function: on medical leave from work for 3 weeks; withdrawn from friends.
Past psychiatric history: no hospitalizations; no suicide attempts; no self-harm. Outpatient: CBT ×12 sessions at 25 (helpful for activation). Medication trials: fluoxetine 20 mg ×10 wk (no response); escitalopram 10 mg ×4 wk (stopped — “jittery, couldn’t sleep”); sertraline 100 mg ×6 wk (partial response, then activation as above, reduced to 50 mg).
Family history: maternal aunt with bipolar I disorder (lithium-responsive); mother with recurrent depression; no completed suicides known.
Substance use: alcohol 1–2 drinks/week; no cannabis or other drugs; caffeine 2 cups/day.
Formulation: recurrent depressive episodes with atypical features, early onset, hypersomnia and hyperphagia, antidepressant-associated activation, two self-reported hypomanic periods meeting duration and symptom criteria on history, and a first-degree-adjacent family history of bipolar I disorder. Leading diagnosis: bipolar II disorder, current episode depressed, moderate, with atypical features. Differential: MDD, recurrent, with atypical features (would require the prior elevated periods to be sub-threshold — collateral from partner and mother requested, with consent). MDQ today: 9 of 13 positive, clustered, moderate impairment. Risk: passive SI without plan, intent or means; no prior attempts; protective factors include sister, dog, and willingness to engage; acute risk low; safety plan completed. Plan and diagnoses continue below.
Why it reads this way: the HPI records each prior episode with duration and treatment, quantifies the current one, and captures the activation episode with specifics (sleep hours, observed speech change, new projects) rather than the word “activated.” The medication trials show that only one antidepressant was an adequate trial. The formulation names the leading diagnosis, the alternative, and what evidence would change the answer — which is what makes the plan defensible whichever way the collateral comes back.
Intake question bank, by domain
Open questions first, then the screens. The bank below is the set of questions that, in practice, most often change the diagnosis or the plan when they are asked — and are most often missing from notes when they are not.
Opening and chief complaint
- What made you decide to come in now, rather than a month ago?
- If treatment worked, what would be different in three months?
- Has anyone else — partner, family, employer — suggested you get help? What did they notice?
Depression
- Over the past two weeks, how many days have you felt down or lost interest in things you usually enjoy?
- How is your sleep — trouble falling asleep, staying asleep, waking early, or sleeping too much? How many hours?
- Has your appetite or weight changed? By how much?
- Do you feel worse in the morning or the evening? Does anything lift your mood, even briefly?
Mania and hypomania
- Has there ever been a period of at least four days when you needed much less sleep than usual and still had energy?
- During that time, did people say you were talking faster, doing more, or acting differently than yourself?
- Did you spend, drive, or take risks in ways you later regretted?
- Has an antidepressant ever made you feel wired, sleepless, or “too good”?
Anxiety and panic
- What do you worry about most, and how much of the day is it in your head?
- Have you had sudden surges of fear with a racing heart, shortness of breath, or feeling you might die? How often? What do you avoid because of them?
Psychosis
- Have you ever heard or seen things other people could not? When you were falling asleep, or fully awake?
- Have you ever felt that people were watching, following, or talking about you, or that messages were meant specifically for you?
Trauma
- Has anything happened to you — at any age — that you still have nightmares or unwanted memories about?
- Do you avoid places, people or conversations that remind you of it? Are you on edge or easily startled?
OCD, ADHD, eating
- Do you have thoughts or images you cannot get rid of, or things you feel you must do a certain way or a certain number of times?
- As a child, did teachers say you could not sit still or did not finish work? Do you lose things, miss deadlines, or start projects you do not finish?
- Do you restrict, binge, purge, or exercise to control weight? What is the most and least you have weighed as an adult?
Substance use
- In a typical week, how many drinks do you have? How often more than four (women) or five (men) in one sitting?
- Cannabis, stimulants, opioids, sedatives, anything else? When was the last time? Has anyone ever been concerned about your use?
- Have you ever had shakes, seizures or hallucinations when you stopped?
Suicide, self-harm and violence
- In the past month, have you wished you were dead, or wished you could go to sleep and not wake up?
- Have you had thoughts of killing yourself? Have you thought about how? Do you have any intention of acting on it? Do you have access to what you would use?
- Have you ever tried to end your life or hurt yourself on purpose? What happened, and what treatment did you get?
- Are there firearms in your home or accessible to you?
- Have you had thoughts of harming anyone else?
Psychiatric, medical and family history
- Have you ever been in a psychiatric hospital? Was it your choice? How long?
- For each medication: what was the highest dose, how long did you stay on it, what did it do, and why did you stop?
- Thyroid problems, seizures, head injuries with loss of consciousness, heart problems, sleep apnea? Any chance of pregnancy?
- Has anyone in your family had depression, bipolar disorder, schizophrenia, drug or alcohol problems, or died by suicide? Did any medication work well for them?
Social and developmental
- What was your childhood like? Were you safe at home?
- Who do you live with, and who would you call in an emergency?
- Work or school right now — how is it going? Any legal issues, past or present? Military service?
Fill-in template
The full initial-evaluation skeleton. Bracketed fields are prompts; delete the ones that do not apply and replace the rest before signing. The MSE line references the MSE template, which you can paste in.
PSYCHIATRIC INITIAL EVALUATION
Date: [ ] Referral source: [ ] Informants: [patient; collateral from ( ) with consent] Reason for visit: [ ]
CHIEF COMPLAINT: "[patient's words]"
HPI: [see HPI prompts — onset, course, symptoms by domain, screens for mania/psychosis/trauma, function, treatment to date, goals]
PAST PSYCHIATRIC HISTORY
Diagnoses (by whom, when): [ ]
Hospitalizations: [number; dates; reason; voluntary/involuntary; length]
Suicide attempts / self-harm: [number; dates; method; medical severity; precipitant; treatment received]
Violence toward others / legal: [ ]
Outpatient treatment: [providers, dates, therapy type, benefit]
Medication trials: [see table]
SUBSTANCE USE
Alcohol [amount/frequency; AUDIT-C; withdrawal history]; cannabis [ ]; tobacco/nicotine [ ]; stimulants [ ]; opioids [ ]; sedatives [ ]; other [ ]. Treatment history [ ]. Last use [ ].
MEDICAL HISTORY
Conditions: [thyroid, seizure, TBI, cardiac, hepatic/renal, sleep apnea, pregnancy/lactation status]
Current non-psychiatric medications and supplements: [ ]
Allergies: [ ] PCP: [ ] Last labs: [CBC, CMP, TSH, lipids, A1c, B12/folate, ECG if indicated]
FAMILY HISTORY
Psychiatric: [depression, bipolar, schizophrenia, suicide, substance use — first- and second-degree]
Medication response in relatives: [ ]
Medical: [ ]
SOCIAL AND DEVELOPMENTAL HISTORY
Birth/development: [ ] Childhood/adverse experiences: [ ] Education: [ ] Employment: [ ] Relationships/children: [ ] Living situation: [ ] Supports: [ ] Legal: [ ] Firearms access: [ ] Military: [ ] Spirituality/culture: [ ]
MSE: [ten domains — see MSE template]
RISK ASSESSMENT
SI: [denies / passive / active]; plan [ ]; intent [ ]; means and access [ ]; prior attempts [ ]; HI [ ]. Risk factors [ ]; protective factors [ ]. Acute risk [ ]; chronic risk [ ]. Safety plan [completed / not indicated]. Means-restriction counseling [ ].
SCREENING: PHQ-9 [ ]; GAD-7 [ ]; MDQ [ ]; PCL-5 [ ]; ASRS [ ]; AUDIT-C [ ]; other [ ]
FORMULATION
[Predisposing, precipitating, perpetuating and protective factors; differential and why the leading diagnosis fits; what would change it.]
DIAGNOSES (DSM-5-TR / ICD-10-CM)
1. [ ] 2. [ ] 3. [ ] Rule out: [ ]
PLAN
Medications: [start/continue/change with dose, rationale, informed consent documented]
Labs/monitoring: [ ]
Psychotherapy/referrals: [ ]
Safety: [ ]
Education provided: [ ]
Follow-up: [ ]
Time / code: [90792 / 90791 / 9920x] [interactive complexity 90785 if criteria met]
Plain text, no formatting.
Psynopsis drafts this structure from the recorded evaluation or from a dictated summary — including the medication-trial table and the mania and psychosis screens — for your review. See the feature overview, or the workflows for psychiatrists and PMHNPs. For which code the evaluation supports, read 90791 vs 90792 and interactive complexity.
How Psynopsis writes the intake
Initial evaluation · draft for review
HPI Onset, course, 5 domains screened
Med trials 3 prior · doses + response table
Hospitalizations 1 (2019) · voluntary · 6 days
Family hx Bipolar I, maternal aunt flag
Risk Passive SI · no plan/intent/means structured
Formulation MDD vs Bipolar II — collateral pending
A ninety-minute evaluation, documented in the structure above.
Psynopsis drafts the HPI, psychiatric history, medication-trial table, substance use, family and social history, MSE, risk assessment and a diagnosis-organized plan from the recorded evaluation or your dictation — then hands it to you to review, correct and sign.
Draft your next intakeEducational content for licensed clinicians about documentation practice. It is not clinical advice and does not replace clinical judgment or your organization’s documentation standards. Examples are synthetic and contain no patient information.