What should be included in a psychiatric follow-up note?

Psychiatric Follow-Up Note Components

A psychiatric follow-up note should systematically document interval changes in symptoms, medication adherence and side effects, current risk assessment, treatment response using validated scales, and an updated treatment plan with clear rationale. 1

Essential Documentation Elements

Interval History Since Last Visit

• Document chronological changes in psychiatric symptoms including mood, anxiety, psychosis, sleep patterns, and impulsivity since the previous appointment 1
• Assess treatment response to current medications and psychosocial interventions, noting both improvements and persistent symptoms 1
• Record any significant life events, psychosocial stressors (financial, housing, legal, occupational, relationship problems), or changes in social support 2
• Evaluate changes in functional status at work, school, or home 1

Medication Management Review

• Review medication adherence systematically and document any missed doses, as non-compliance is a common reason for relapse and increased morbidity 1
• Evaluate side effects systematically as they are a primary cause of medication non-compliance and treatment failure 1
• Monitor specifically for extrapyramidal symptoms, sedation, anticholinergic effects, and metabolic changes in patients taking antipsychotics 1
• Document all current medications including prescribed medications, over-the-counter drugs, herbal supplements, and vitamins 2, 1
• Record any changes in medication regimen since last visit 1

Risk Assessment at Every Visit

• Evaluate current suicidal ideation, plans, and intent at each follow-up appointment, including passive thoughts of death 2, 1
• If suicidal ideas are present, assess: intended course of action if symptoms worsen, access to suicide methods including firearms, possible motivations for suicide, reasons for living, and quality of therapeutic alliance 2
• Assess current aggressive or homicidal ideation, particularly in patients with a history of violence 2, 1
• Document an updated estimate of suicide risk with influencing factors 2

Mental Status Examination

• Assess appearance, behavior, and general presentation 2
• Evaluate speech including fluency and articulation 2
• Document mood (patient's subjective report) and affect (clinician's observation) 2
• Assess thought process (logical, tangential, circumstantial, flight of ideas) and thought content (delusions, obsessions, preoccupations) 2
• Evaluate perception (hallucinations, illusions) and cognition (orientation, attention, memory) 2
• Document level of anxiety and any psychotic symptoms 2

Measurement-Based Care

• Utilize validated rating scales such as PHQ-9 for depression or GAD-7 for anxiety to objectify symptom severity and track treatment outcomes over time 1
• Compare current scores to baseline and previous visits to quantify treatment response 1
• This approach provides objective data to guide treatment decisions and demonstrates clinical progress 1

Substance Use Monitoring

• Reassess use of tobacco, alcohol, and other substances at each visit 2
• Evaluate for misuse of prescribed or over-the-counter medications 2
• Document any changes in substance use patterns since last visit 2

Medical Status Updates

• Review any new medical problems, hospitalizations, or emergency department visits since last appointment 2
• Document changes in non-psychiatric medications that could affect psychiatric symptoms 2
• Assess for medication interactions between psychiatric and medical treatments 2

Treatment Plan and Rationale

• Document the updated treatment plan with clear rationale for any changes in medication, dosing, or psychosocial interventions 2, 1
• Explain the specific factors that influenced treatment decisions 2
• Include patient's treatment preferences and document collaboration in decision-making 2
• Address any barriers to treatment adherence and construct plans to overcome obstacles 2

Visit Frequency Guidelines

• Schedule weekly visits initially after starting new medications or during symptom exacerbations to establish rapport and ensure compliance 1
• Maintain monthly physician contact as minimum once stabilized to adequately monitor symptom course, side effects, and compliance 1
• More frequent visits may be needed for high-risk patients or those with poor treatment response 1

Critical Follow-Up Actions

For Poor Treatment Response

• After 8 weeks of treatment with poor symptom reduction despite good compliance, alter the treatment course by adding a psychological or pharmacological intervention, changing the specific medication, or referring to individual psychotherapy if group therapy has not proved helpful 2
• Reassess diagnosis if symptoms are not responding as expected 2

Monitoring Compliance

• Assess follow-through with referrals to individual or group psychological/psychosocial services and patient satisfaction with these services 2
• If compliance is poor, assess and construct a plan to circumvent obstacles to compliance, or discuss alternative interventions that present fewer obstacles 2

Documentation Requirements

• Include date and time of evaluation 1
• Review of previous records and interval changes 1
• Authentication by the evaluating clinician 3
• All sections should be clearly documented with appropriate detail 3

Common Pitfalls to Avoid

• Do not use "no-suicide contracts" as they are ineffective; instead, develop safety plans with specific coping strategies and emergency contacts 3
• Avoid assuming medication adherence without directly asking about missed doses 1
• Do not neglect systematic side effect assessment, as this is a primary cause of treatment failure 1
• Ensure risk assessment is performed at every visit, not just initial evaluations 1