How long should a psychiatric progress note be?

Long enough to show what changed, what you observed, what you decided and why. A stable medication-management visit fits comfortably in 250–400 words when the A&P is organized by diagnosis; a visit with a medication change, a risk reassessment and psychotherapy is typically 500–700. Length is not a proxy for quality — an auditor reads the MDM, the risk section and the plan, not the padding.

Is a SOAP note the same as a psychiatric progress note?

A SOAP note is one way to organize a progress note (Subjective, Objective, Assessment, Plan). Psychiatric follow-up notes usually work better with named sections — interval history, medications, screening, MSE, risk, A&P by diagnosis — because payers and reviewers look for those elements specifically. Either structure is acceptable if all of the elements are present.

Do I need a full MSE in every follow-up note?

You need an MSE that reflects that day’s encounter. For a stable visit it can be brief, but it should cover the domains relevant to your decisions — at minimum appearance, behavior, speech, mood, affect, thought process, thought content (with SI/HI), perception, cognition, insight and judgment. What you cannot do is copy forward last month’s normal exam.

Can I bill 99214 and 90833 on the same visit?

Yes, when both services are medically necessary and separately documented: the E/M level is chosen by medical decision-making (not time), and the psychotherapy is documented with its own time (16–37 minutes for 90833), modality, interventions and patient response. See the E/M coding guide for the details and pitfalls.

Psychiatric Progress Note Template & Example

What a psychiatric progress note must contain

A follow-up note has two readers with different questions. The clinical reader — you in six months, a covering colleague, the next prescriber — wants to know what changed and why you did what you did. The administrative reader — a payer auditor, a peer reviewer, a licensing board — wants to see that each billed element is present and internally consistent. The structure below satisfies both without writing the note twice.

Section	What goes in it	Why it matters
Interval history	Symptom-by-symptom change since the last visit, function (work, relationships, ADLs), stressors, substance use, hypomania and psychosis screens, ED visits or hospitalizations	Supports the status of each diagnosis and the “problems addressed” element of MDM
Medications, adherence, side effects	Each drug with dose and frequency, missed doses, side effects, benefit, OTC and supplements, allergies, monitoring due	Prescription drug management is what usually places risk at “moderate”; adherence explains non-response
Screening scores	PHQ-9 (with item 9), GAD-7, plus disorder-specific tools (MDQ, ASRS, Y-BOCS, AUDIT-C, AIMS); always with the prior score	Objective trend; measurement-based care; counts as data reviewed
Mental status exam	Ten domains, reflecting today’s encounter (MSE examples)	The exam findings that justify the assessment
Risk assessment	SI/HI as separate facts (passive vs active, plan, intent, means, access), prior attempts, protective factors, acute and chronic risk with rationale, safety plan status	The section most scrutinized after an adverse event
Assessment and plan by diagnosis	Each diagnosis with ICD-10-CM code, status word, evidence, and a plan that names the medication decision, monitoring, therapy and education	Shows clinical reasoning; makes “stable chronic” vs “not at goal” explicit for MDM
Psychotherapy (if billed)	Minutes, modality, interventions, patient response — separate from the E/M content	Required for 90833/90836/90838; not separable, not billable
MDM or time	Problems, data and risk elements named, or total time on the date of service with what it included	Selects and defends the E/M level

Example · Follow-up note, medication management with psychotherapy (99214 + 90833)

A synthetic established-patient visit for major depressive disorder and generalized anxiety disorder, four weeks after a sertraline increase. Read it for the structure: every section is short, every decision has a reason next to it, and the psychotherapy is documented as its own service.

PSYCHIATRIC PROGRESS NOTE Visit: Established patient, in person. Informant: patient. CC: “Still tired, but the mornings are better.” Follow-up for MDD and GAD; medication review. INTERVAL HISTORY Seen 4 weeks ago; sertraline increased 50 → 100 mg. Mood “a 5 out of 10, was a 3.” Sleep 6–7 h, early-morning awakening twice weekly. Appetite improved, weight stable. Energy low in the afternoons. Anhedonia improving — returned to the climbing gym twice this month. Concentration at work “about 70%.” Financial worry persists but “less loud.” No panic attacks since last visit (previously 2/week). Denies decreased need for sleep, racing thoughts or increased goal-directed activity. Denies AH/VH. Alcohol 2–3 drinks/week, no binge episodes; no cannabis; no tobacco. No ED visits or hospitalizations. MEDICATIONS · ADHERENCE · SIDE EFFECTS - Sertraline 100 mg qAM — missed 2 doses in 4 weeks (travel). Initial nausea resolved. Reports delayed orgasm, “tolerable, don’t change anything yet.” - Trazodone 50 mg qHS PRN — ~3 nights/week; no morning grogginess. No OTC/supplements. NKDA. SCREENING PHQ-9 = 12 (prior 19); item 9 = 0. GAD-7 = 9 (prior 15). C-SSRS screener negative for past month. MSE Appears stated age, well-groomed. Cooperative, good eye contact, no psychomotor abnormality. Speech normal in rate and volume. Mood “a 5 out of 10.” Affect mildly constricted, brighter than prior visit, congruent. Thought process linear and goal-directed. Thought content: denies SI/HI; no delusions or obsessions. Denies AH/VH. Alert and oriented ×4; attention intact. Insight good; judgment good. RISK ASSESSMENT Denies current passive or active SI; last passive SI reported 8 weeks ago, resolved. No plan, intent or means; no prior attempts. No firearms in the home (re-confirmed today). Protective factors: partner, employment, engaged in care, future-oriented. Acute risk: low. Chronic risk: low-to-moderate (recurrent MDD, prior passive SI). Safety plan from intake reviewed, unchanged. ASSESSMENT AND PLAN 1. Major depressive disorder, recurrent, moderate (F33.1) — IMPROVING. Partial response at 4 weeks on sertraline 100 mg (PHQ-9 19 → 12); residual early-morning awakening, low energy, reduced concentration. Plan: continue sertraline 100 mg; if PHQ-9 remains above 9 at next visit, increase to 150 mg. Counseled on sexual side effect; patient prefers to monitor for now. Continue behavioral activation (see psychotherapy). 2. Generalized anxiety disorder (F41.1) — IMPROVING. GAD-7 15 → 9; no panic attacks in 4 weeks. Plan: continue sertraline; continue paced-breathing practice; benzodiazepine not indicated. 3. Insomnia symptoms, secondary to MDD — IMPROVING. Trazodone PRN 3 nights/week, effective, no next-day sedation. Plan: continue; reviewed consistent wake time and no screens after 10 p.m. 4. Alcohol use, below risk thresholds — no diagnosis; monitored. Counseled on effect on sleep continuity. PSYCHOTHERAPY (90833) 20 minutes, individual, CBT-based, separate from and in addition to the E/M service. Focus: behavioral activation — reviewed activity log; scheduled two additional activities for the coming week (Saturday hike, call with sister). Cognitive restructuring of “I’m falling behind at work” using evidence for and against; patient generated a balanced alternative thought without prompting. Homework: activity log, one thought record. MEDICAL DECISION-MAKING Problems: two chronic illnesses, one not at treatment goal — moderate. Data: PHQ-9 and GAD-7 reviewed — limited. Risk: prescription drug management — moderate. E/M level 99214 selected by MDM. Psychotherapy time documented separately; time not used for E/M selection. FOLLOW-UP 4 weeks, sooner if worsening. Return precautions reviewed; crisis line (988) reviewed.

Why it reads this way: the interval history is organized by symptom so the status word in each A&P line has evidence behind it; the hypomania screen is written out because the patient is on an antidepressant; the sexual side effect is recorded with the patient’s preference, which is what makes the “no change” decision defensible; and the MDM paragraph names the elements rather than asserting a level. The psychotherapy block has minutes, modality, intervention and response — the four things a 90833 audit looks for.

Assessment and plan, organized by diagnosis

A single-paragraph plan (“continue meds, follow up 4 weeks”) is the most common weakness in psychiatric follow-up notes. It hides which diagnosis each decision belongs to, makes stability impossible to verify and gives an auditor nothing to support “chronic illness with progression.” Organizing the A&P by diagnosis fixes all three. Each entry has four parts: the diagnosis with its code, a status word, the evidence for that status, and the plan.

ASSESSMENT AND PLAN 1. Bipolar I disorder, most recent episode depressed, in partial remission (F31.75) — STABLE. No depressive episode in 5 months; PHQ-9 6 (prior 7). No hypomanic or manic symptoms on structured screen; sleep 7–8 h. Plan: continue lithium carbonate ER 900 mg qHS. Lithium level 0.8 mEq/L (drawn 12 h post-dose, 2 weeks ago), creatinine and TSH within normal limits — next level and TSH/creatinine in 6 months or sooner with dose change, dehydration or new NSAID/ACE inhibitor. Counseled again on hydration and NSAID avoidance. 2. Attention-deficit/hyperactivity disorder, combined presentation (F90.2) — IMPROVING. ASRS part A 4/6 (prior 6/6); reports finishing work tasks on time 4 of 5 days. Plan: continue methylphenidate ER 36 mg qAM. BP 118/76, HR 78, appetite adequate, weight stable. PDMP reviewed today, consistent with prescribing. Refill 30 days, no early refills. 3. Tobacco use disorder, moderate (F17.200) — WORSENING. Back to 10 cigarettes/day from 4 after job change. Plan: patient declines varenicline today; agreed to nicotine patch 14 mg plus 2 mg lozenge PRN; quit date set for the 1st; quitline referral given. Note: smoking cessation may raise clozapine/olanzapine levels — not applicable to current regimen; documented for future reference.

Why it reads this way: the lithium entry shows the monitoring loop — level, timing of the draw, renal and thyroid labs, interaction counseling — in one place. The stimulant entry records vitals, PDMP review and refill parameters, the items a controlled-substance audit checks. The status words are not decoration: two stable or improving chronic illnesses plus one worsening one is what makes the MDM “problems” element moderate.

Fill-in template

Bracketed fields are prompts. Delete the lines that do not apply (for example the psychotherapy block on a medication-only visit) and replace every bracket before signing. The MDM line is written so you name the elements rather than the level; the level follows.

PSYCHIATRIC PROGRESS NOTE Date of service: [ ] Visit: [established] · [in person / video / audio-only] Informant: [patient / + family] CC: "[patient's words]" — follow-up for [diagnoses]; medication review. INTERVAL HISTORY Since last visit ([date]): mood [ ], sleep [hours, onset/maintenance], appetite/weight [ ], energy [ ], interest [ ], concentration [ ], anxiety/panic [ ], irritability [ ]. Hypomania/mania screen: [decreased need for sleep / racing thoughts / increased activity — denies/endorses]. Psychosis screen: [ ]. Substance use: alcohol [ ], cannabis [ ], tobacco [ ], other [ ]. Stressors/function: work [ ], relationships [ ], ADLs [ ]. ED visits/hospitalizations: [none]. MEDICATIONS · ADHERENCE · SIDE EFFECTS - [drug dose frequency] — adherence [missed x doses/4 wk]; side effects [ ]; benefit [ ] - [drug dose frequency] — adherence [ ]; side effects [ ]; benefit [ ] OTC/supplements: [ ] Allergies: [ ] Labs/monitoring due: [ ] SCREENING PHQ-9 [ ] (prior [ ]); item 9 = [ ]. GAD-7 [ ] (prior [ ]). [Other: MDQ / ASRS / AUDIT-C / AIMS] MSE Appearance [ ]. Behavior [ ], eye contact [ ], psychomotor [ ]. Speech [ ]. Mood "[ ]". Affect [ ]. Thought process [ ]. Thought content: SI [denies / passive / active] · plan [ ] · intent [ ] · means [ ]; HI [ ]; delusions [ ]. Perception: AH/VH [ ]. Cognition: A&O ×[ ], attention [ ], memory [ ]. Insight [ ]; judgment [ ]. RISK ASSESSMENT SI/HI as above. Prior attempts [ ]. Access to means [firearms: ]. Protective factors [ ]. Acute risk [low / moderate / high]; chronic risk [ ]. Safety plan [reviewed / updated / not indicated]. Rationale: [ ]. ASSESSMENT AND PLAN (by diagnosis) 1. [Diagnosis (ICD-10-CM)] — [IMPROVING / STABLE / WORSENING / IN REMISSION]. [Evidence: symptoms, scores, function.] Plan: [medication continue/adjust with dose and rationale]; [monitoring/labs]; [psychotherapy/referral]; [patient education]. 2. [Diagnosis] — [status]. Plan: [ ]. 3. [Diagnosis] — [status]. Plan: [ ]. PSYCHOTHERAPY (if provided; 90833/90836/90838) [ ] minutes, separate from and in addition to the E/M service. Modality [CBT / supportive / IPT / ...]. Focus [ ]. Interventions [ ]. Patient response [ ]. Homework [ ]. MEDICAL DECISION-MAKING Problems: [ ]. Data: [ ]. Risk: [prescription drug management / ...]. E/M level [ ] selected by [MDM / total time ( ) min — time not used if psychotherapy add-on billed]. FOLLOW-UP [ ] weeks; return precautions [ ]; crisis resources reviewed (988).

Plain text, no formatting.

Common errors in psychiatric progress notes

Copy-forward. A copied interval history, MSE or plan that contradicts the same visit’s medication change is the fastest way to lose an audit. If your EHR pre-fills from the last note, treat every pre-filled sentence as unverified until you have re-read it against today’s visit.
No MDM elements and no time. “99214” at the bottom of a note is a claim, not documentation. Name the problems, the data and the risk — or state total time on the date of service and what it included.
SI recorded as a single word. “SI: denies” after a PHQ-9 item 9 score of 1 is an internal contradiction. Record passive vs active, plan, intent, means, access and protective factors every time ideation is raised by the patient, a screen or a family member.
Medication list not reconciled. The list should match what the patient is actually taking, including missed doses, PRN frequency and OTC agents; “continue current medications” does not tell a covering clinician what those are.
Psychotherapy not separately identifiable. An add-on code needs its own minutes, modality, interventions and patient response. “Supportive therapy provided” with no time is not billable.
Screening scores without trend. A PHQ-9 of 12 means something different after 19 than after 8. Always record the prior score.
Controlled substances without the checklist. Stimulants and benzodiazepines need the PDMP review, vitals or sedation assessment, and refill parameters documented at each prescribing visit in most states.

Psynopsis drafts this structure from a recorded visit or a post-session dictation — interval history by symptom, reconciled medications, MSE, structured risk and a diagnosis-organized A&P — for you to review and sign. See the feature overview, or how the workflow fits psychiatrists and PMHNPs. For the coding side, read the 99213 vs 99214 guide for psychiatry.

How Psynopsis writes the progress note

Progress note · draft for review

Interval Sleep 6–7 h · early waking ×2/wk

Sertraline 100 mg qAM · 2 missed doses reconciled

PHQ-9 12 (prior 19) · item 9 = 0

SI Denies · no plan, intent, means structured

A&P 3 diagnoses · status + plan each

MDM elements Rx management · 2 chronic your review

Every section, drafted from the visit and organized by diagnosis.

Interval history, reconciled medication list with adherence and side effects, MSE, structured SI/HI, screening trends and a diagnosis-by-diagnosis A&P — drafted from a recorded visit or a two-minute post-session dictation, then reviewed and signed by you.

Draft your next progress note

Educational 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.

Psychiatric progress note template (with a full example note)

What a psychiatric progress note must contain

Example · Follow-up note, medication management with psychotherapy (99214 + 90833)

Assessment and plan, organized by diagnosis

Fill-in template

Common errors in psychiatric progress notes

Psychiatric progress note FAQ

Progress notes that finish when the visit does.