Psychiatry Progress Note Template

What is a Psychiatry Progress Notes Template?

A  template is a tool for psychiatrists to use with their patients at appointments following their initial consultation. Psychiatrists may see their patients on a short or long term basis depending on their progress, and having a written record of the patient’s progress between sessions with their psychiatrist is an important clinical decision making tool.

This specific progress notes template provides a structure for the progress notes, standardizing the progress note taking process. This template can be used as a PDF or from within the Carepatron platform, and while we recommend storing the completed template digitally, you can also print it out and fill it in by hand if you prefer.

How to Use This Progress Note Template for Psychiatry

It’s easy to start using this psychiatric progress note template in your psychiatry practice. Just follow these simple steps:

Download the PDF

Step one is to download the free PDF resource and save it locally so you can edit it digitally. Alternatively, you can print it out and fill it in by hand, or use the version of the template available within Carepatron. Check out the explainer video on this page for help doing this.

Fill in your patient details

As with any medical document, ensure you include your patient’s name, date of birth, optional identifier, and date of your session.

Medication Review

The medication review section is designed to separate specific information relating to your patient’s medication regime, schedule, and response from the rest of the progress notes. Include any side-effects they have experienced, their self-reporting of their response to the medication, their reported compliance, and any changes you recommend to their medication.

Progress Notes

This is the biggest section in this note as it includes the body of your psychiatric progress notes on your patient. Include any pertinent details of their progress since their last session with you.

Additional Notes

We have included space for any additional notes you may need to take, such as for co-ordination of care, ordering tests, results, follow-up appointments, or resources provided.

Sign and store securely

The last step is to sign the psychiatric progress note and store it in a HIPAA-compliant way to ensure the security of your patient’s sensitive medical information.

Who Can Use this Psychiatry Template?

This progress notes template was designed for use by psychiatrists, but could also be used by:

• Primary-care physicians
• Psychiatric mental health nurses
• Psychiatric residents or trainee doctors

Or anyone else who can legally make adjustments to a patient’s medication schedule. Additionally, medical transcriptionists who routinely type psychiatrist letters may choose to use this template to structure the practitioner’s notes if they have specified this prior.

Why is This Template Useful For Psychiatrists?

Shareability

Your psychiatric progress notes may need to be shared with other members of your patient’s care team such as nurses, their primary medical practitioner, or other mental health workers. As such, having a clearly laid out template that others can quickly interpret and use makes life easier for everyone.

Improve Organization

Templates help to standardize your psychiatric practice. By using the same progress note template each time you have a follow-up appointment, you can help to ensure you are providing a consistent service to all of your patients.

Save time formatting

We have done all the formatting for you in this free PDF download, just fill in the headings and you will have a well-formatted and professionally presented psychiatric progress note.

Benefits of Using a Free Psychiatry Progress Note Template 

Provide Evidence to third parties

Your progress notes are legal medical records, and as such, can be requested by insurance companies or in the event of a legal situation. Using a standardized template for your progress notes provides great evidence of your clinical decision-making process for your patient. 

Streamline your practice’s note-taking

Sick of everyone using a different method to take notes? This template can be used by everyone in a practice to standardize a practice’s medical record-keeping process. Ensuring every practitioner uses the same template also helps to provide continuation of care should a patient have to transfer between psychiatrists. 

Go paperless

This template can be kept completely digital, and filled in easily using the interactive PDF text boxes. Going paperless has huge security, time-saving, and accessibility benefits for your practice, as well as saving a few trees.

Aid your Reflective Practice

Having a standardized template for progress notes allows for easier comparison of clinical decision-making processes over time or between patients. Reflecting on commonalities across patients is easy when all the progress notes have been completed with the same format and layout. 

Provide detailed progress notes to your clients

Your patients can legally request access to their psychiatric notes, and showing them detailed progress notes taken on a standardized template will reassure them you are addressing all aspects of their care every session.