A psychiatric note is a document used by mental health professionals to record and communicate information about a patient’s mental health condition and treatment. It typically includes a summary of the patient’s subjective complaints, objective observations made by the clinician, a list of differential diagnoses, a treatment plan, and any follow-up or referral recommendations. The format of the note may vary, but one commonly used format is the Focused SOAP (Subjective, Objective, Assessment, and Plan) note.
In the subjective section of the note, the clinician should record the patient’s own words and descriptions of their symptoms and concerns. This may include information about the duration and severity of the symptoms, as well as how the symptoms are impacting the patient’s functioning in daily life.
In the objective section, the clinician should record any observations made during the psychiatric assessment, such as the patient’s appearance, behavior, and mental status. This may include information about the patient’s mood, affect, thought processes, and cognitive functioning.
The assessment section of the note should include a summary of the differential diagnoses considered by the clinician, as well as the primary diagnosis and why it was chosen. The clinician should also describe how the primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
The plan section should outline the treatment plan for the patient, including any psychopharmacologic agents that will be used and any alternative treatments that may be considered. The clinician should also describe their follow-up plan and any referrals they may recommend as a result of the treatment session. In addition, the plan should include a discussion of at least one social determinant of health as it relates to the patient’s condition and how it may impact their treatment, as well as at least one health promotion activity and one patient education consideration for improving health disparities and inequities in the realm of psychiatry and mental health.
Finally, the reflection notes should include any reflections on the treatment session and any changes the clinician would make if they had the opportunity to conduct the session again. If a follow-up session was conducted, the clinician should also include information about the success of the interventions and any additional recommendations for treatment. If a follow-up session was not conducted, the clinician should discuss what their next intervention would be.
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