Examples of Psychiatric Documentation: Intake Note and E/M Note with Add-on Psychotherapy
Properly documented psychiatric notes must include specific elements to meet documentation requirements and withstand audit scrutiny, particularly when including add-on psychotherapy codes.
Psychiatric Intake Note Example
IDENTIFYING INFORMATION
- Patient: Jane Doe
- DOB: 01/15/1985
- Date of Service: 07/15/2023
- Time: 9:00 AM - 10:15 AM (75 minutes)
- Location: Outpatient Psychiatric Clinic
- Provider: Dr. Smith, MD
- Billing Codes: 90792 (Psychiatric diagnostic evaluation with medical services)
- Add-on Code: 90833 (Psychotherapy, 30 minutes with E/M service)
CHIEF COMPLAINT
"I've been feeling depressed and anxious for the past three months since losing my job."
HISTORY OF PRESENT ILLNESS
Patient is a 38-year-old female presenting with symptoms of depression and anxiety that began approximately three months ago following job loss. Symptoms include depressed mood daily, anhedonia, insomnia (difficulty falling and staying asleep), decreased appetite with 10-pound weight loss, poor concentration, fatigue, and occasional passive suicidal ideation without plan or intent. Patient reports increased worry about finances and future employment. Denies prior psychiatric treatment.
PSYCHIATRIC REVIEW OF SYSTEMS
- Mood: Depressed, anxious
- Sleep: Initial and middle insomnia, averaging 4-5 hours per night
- Appetite: Decreased with unintentional weight loss
- Energy: Significantly decreased
- Concentration: Poor, affecting daily functioning
- Anxiety symptoms: Excessive worry, tension, occasional shortness of breath
- Panic attacks: Denies
- Psychotic symptoms: Denies hallucinations, delusions, or paranoia
- Suicidal/homicidal ideation: Passive thoughts of "not wanting to wake up" but denies active suicidal ideation, plan, or intent; no homicidal ideation
PSYCHIATRIC HISTORY
- Past diagnoses: None
- Prior hospitalizations: None
- Previous treatments: None
- Medication trials: None
- Suicide attempts: None
- Self-injurious behaviors: None
SUBSTANCE USE HISTORY
- Alcohol: 1-2 glasses of wine weekly, no increase during current stressors
- Tobacco: None
- Cannabis: None
- Other substances: Denies use of illicit substances
- Prescription medications: Denies misuse
MEDICAL HISTORY
- Current medical conditions: Hypothyroidism, well-controlled
- Past medical conditions: None significant
- Allergies: Penicillin (hives)
- Current medications: Levothyroxine 75mcg daily
- Surgeries: Appendectomy (2010)
FAMILY HISTORY
- Mother: History of depression, treated with medication
- Father: No psychiatric history
- Siblings: Brother with anxiety disorder
SOCIAL HISTORY
- Education: Bachelor's degree in Business Administration
- Employment: Recently unemployed (3 months), previously marketing manager for 8 years
- Living situation: Lives alone in apartment
- Relationship status: Single, divorced 2 years ago
- Children: None
- Support system: Close relationship with mother and two friends
- Financial status: Currently using savings, concerned about long-term stability
- Legal history: None
DEVELOPMENTAL HISTORY
Normal developmental milestones. No history of childhood trauma or abuse.
MENTAL STATUS EXAMINATION
- Appearance: Well-groomed female appearing stated age, appropriate dress
- Behavior: Cooperative, good eye contact, psychomotor retardation noted
- Speech: Normal rate, rhythm, and volume
- Mood: "Sad and worried"
- Affect: Congruent with mood, restricted range
- Thought process: Linear, logical, goal-directed
- Thought content: No delusions, obsessions, or paranoia; preoccupied with job loss
- Perceptions: No hallucinations or illusions
- Cognition: Alert and oriented x4, intact memory, normal attention and concentration during interview
- Insight: Good understanding of current condition
- Judgment: Intact
- Impulse control: Good
- Suicidal/homicidal ideation: Passive suicidal ideation without plan or intent; no homicidal ideation
RISK ASSESSMENT
- Suicide risk: Low to moderate based on passive suicidal ideation, protective factors include good support system, no prior attempts, willingness to engage in treatment
- Violence risk: Low, no history of violence, no current homicidal ideation
- Self-neglect risk: Low, maintaining self-care despite symptoms
DIAGNOSTIC IMPRESSION
- Major Depressive Disorder, moderate, single episode (F32.1)
- Generalized Anxiety Disorder (F41.1)
- Rule out Adjustment Disorder with mixed anxiety and depressed mood
MEDICAL DECISION MAKING
Moderate complexity based on:
- Multiple diagnoses requiring management
- Moderate risk due to presence of suicidal ideation
- Comprehensive review of systems and past records
- Need for medication management and psychotherapy
PSYCHOTHERAPY COMPONENT (20 minutes)
Conducted supportive psychotherapy focused on addressing patient's immediate concerns about job loss and financial stress. Used cognitive-behavioral techniques to identify and challenge negative thought patterns related to self-worth following job loss. Patient was receptive to identifying cognitive distortions and began to recognize catastrophic thinking patterns. Homework assigned to track negative thoughts and practice reframing exercises.
TREATMENT PLAN
- Medication: Start sertraline 50mg daily for depression and anxiety
- Psychotherapy: Weekly individual CBT sessions
- Referral to employment counseling services
- Safety plan developed and provided to patient
- Follow-up appointment scheduled in 2 weeks
INFORMED CONSENT
Discussed risks, benefits, and alternatives of proposed treatment. Patient verbalized understanding and agreed to treatment plan.
Psychiatric E/M Follow-up Note Example
IDENTIFYING INFORMATION
- Patient: Jane Doe
- DOB: 01/15/1985
- Date of Service: 07/29/2023
- Time: 2:00 PM - 2:45 PM (45 minutes total: 25 minutes E/M, 20 minutes psychotherapy)
- Location: Outpatient Psychiatric Clinic
- Provider: Dr. Smith, MD
- Billing Codes: 99214 (Office visit, established patient, moderate complexity)
- Add-on Code: 90833 (Psychotherapy, 20 minutes with E/M service)
CHIEF COMPLAINT
Follow-up for depression and anxiety, medication management.
INTERVAL HISTORY
Patient reports partial improvement in depressive symptoms since starting sertraline 50mg daily two weeks ago. Sleep has improved to 6 hours nightly, and appetite is slightly better. Continues to experience morning anxiety and rumination about job prospects. Has applied for three positions and has one interview scheduled next week. Completed thought records as assigned and identified patterns of catastrophic thinking.
REVIEW OF SYSTEMS
- Psychiatric: As noted in HPI
- Constitutional: Denies fever, chills, fatigue improved from last visit
- Cardiovascular: Denies chest pain, palpitations
- Gastrointestinal: Mild nausea with medication, resolving after first week
- Neurological: Denies headaches, dizziness
MEDICATION REVIEW
- Sertraline 50mg daily - reports taking as prescribed with mild initial side effects (nausea, increased anxiety) that have largely resolved
- Levothyroxine 75mcg daily - continues as prescribed
MENTAL STATUS EXAMINATION
- Appearance: Well-groomed, appropriate dress
- Behavior: Cooperative, improved psychomotor activity
- Speech: Normal rate and volume
- Mood: "Better than last time, still anxious"
- Affect: Improved range, less restricted
- Thought process: Linear and goal-directed
- Thought content: No delusions or paranoia, less preoccupation with job loss
- Perceptions: No hallucinations
- Cognition: Alert and oriented x4
- Insight: Good
- Judgment: Intact
- Suicidal/homicidal ideation: Denies current suicidal or homicidal ideation
ASSESSMENT
- Major Depressive Disorder, moderate, single episode (F32.1) - Partially responding to medication and psychotherapy
- Generalized Anxiety Disorder (F41.1) - Persistent symptoms, particularly morning anxiety
MEDICAL DECISION MAKING
Moderate complexity based on:
- Management of two stable psychiatric diagnoses
- Prescription medication management with assessment of efficacy and side effects
- Low risk of morbidity without treatment
- Coordination with psychotherapy approach
PSYCHOTHERAPY COMPONENT (20 minutes)
Conducted cognitive-behavioral therapy focused on identifying and challenging negative automatic thoughts related to job search and self-worth. Reviewed thought records completed by patient, which revealed patterns of catastrophizing and all-or-nothing thinking. Practiced cognitive restructuring techniques and developed more balanced alternative thoughts. Patient demonstrated good understanding and application of concepts. Assigned continued thought records with focus on developing alternative perspectives.
TREATMENT PLAN
- Medication: Increase sertraline to 75mg daily for one week, then 100mg daily
- Continue weekly psychotherapy sessions focusing on CBT techniques
- Continue employment counseling
- Follow-up in 3 weeks for medication management and psychotherapy
INFORMED CONSENT
Discussed risks and benefits of medication adjustment. Patient verbalized understanding and agreed to plan.
Key Documentation Elements for Audit Compliance
Clear time documentation: Specify total time spent and time allocated to E/M versus psychotherapy components 1
Separate documentation of E/M and psychotherapy components: Clearly delineate the medical management versus psychotherapy work 1
Specific psychotherapy approach: Document the specific therapeutic technique used (e.g., CBT, supportive, insight-oriented) 2
Medical decision-making elements: Document complexity factors that justify the E/M code level 1
Risk assessment: Include thorough evaluation of suicide and violence risk 1
Treatment plan: Document comprehensive plan addressing both medication and psychotherapy components 2
Informed consent: Document that risks, benefits, and alternatives were discussed 2
Mental status examination: Include comprehensive elements as outlined in guidelines 1
Follow-up planning: Document specific follow-up timeline and monitoring parameters 2
Homework or between-session activities: Document specific assignments given to patient 2