Psychiatry notes are one of the most important tools in mental health care. They help psychiatrists record patient symptoms, clinical thinking, treatment decisions, and progress over time. Good psychiatry notes support better patient care, improve communication with other professionals, and protect the clinician legally. Poor or unclear notes can lead to confusion, missed risks, and treatment errors.
Unlike many other medical specialties, psychiatry relies heavily on patient communication, behavior, and mental status rather than lab tests or imaging. This makes psychiatric notes especially important. Every word matters. This guide explains psychiatry notes in a practical way to help you write better notes.
What Are Psychiatry Notes?
Psychiatry notes, also called psychiatric notes, are written records of a psychiatric evaluation or follow-up visit. They describe the patient’s mental health concerns, emotional state, behavior, diagnosis, treatment plan, and response to care. These notes are used in outpatient clinics, hospitals, emergency settings, and telepsychiatry visits.
These notes are not just summaries of what the patient says. They show how the psychiatrist listens, observes, analyzes, and makes clinical decisions. A well-written psychiatry note clearly explains what is happening, why it matters, and what will be done next. This clarity is critical when treating complex mental health conditions.
Psychiatric notes also serve many readers. Besides the psychiatrist, they may be reviewed by therapists, primary care providers, nurses, insurance companies, legal teams, and sometimes the patients themselves. For this reason, notes must be professional, respectful, and easy to understand.
Important of Psychiatric Notes
Psychiatric notes support safe and effective care. Mental health treatment often lasts months or years, and symptoms can change slowly. Clear documentation helps track these changes over time. It allows psychiatrists to see patterns, measure progress, and adjust treatment when needed.
Psychiatry notes also improve communication. Many patients receive care from multiple providers. When notes are clear, other clinicians can quickly understand the diagnosis, risks, medications, and treatment goals. This reduces mistakes and improves coordination of care.
From a legal and ethical point of view, psychiatry notes are essential. They show that proper assessments were done, risks were evaluated, and informed decisions were made. In cases involving safety concerns, such as suicidal thoughts, good documentation can be critical.
Common Types of Psychiatric Notes
There are several types of psychiatric notes used in daily practice. Each has a different purpose, but all must be clear and accurate.
Psychiatric evaluation notes are written during the first visit. They include a full history, mental status exam, diagnosis, and initial treatment plan. These notes are usually longer and more detailed.
Psychiatric progress notes are written during follow-up visits. They focus on symptom changes, medication response, side effects, therapy progress, and updates to the treatment plan. Progress notes are the most common type of psychiatry notes.
Other types include medication management notes, inpatient daily notes, discharge summaries, and consultation notes. Regardless of the type, the same core principles apply: clarity, structure, and clinical reasoning.
What Is a Psychiatric Progress Note?
A psychiatric progress note documents what happens during a follow-up psychiatric visit. It shows how the patient is doing since the last appointment and whether the current treatment is working. These notes are usually written at every visit and are central to psychiatric care.
They help answer key questions. Is the patient improving, worsening, or staying the same? Are medications effective and tolerated? Are there new symptoms or risks? Does the treatment plan need to change? Because progress notes are written often, they must be efficient but still detailed. They should clearly connect symptoms to clinical decisions. Over time, a series of well-written psychiatric progress notes tells the full story of the patient’s mental health journey.
The Psychiatric SOAP Note Format
One of the most widely used formats for psychiatry notes is the Psychiatric SOAP note. SOAP stands for Subjective, Objective, Assessment, and Plan. This structure helps organize information in a logical and consistent way.
Using the SOAP format makes notes easier to read, write, and review. It also encourages clear clinical thinking by separating patient reports from observations and medical decisions. For psychiatry, the SOAP format works especially well because it balances subjective experience with objective assessment.
Below is a detailed explanation of each section of the Psychiatric SOAP note.
Subjective Section
The Subjective section records what the patient reports in their own words. This includes symptoms, mood, thoughts, concerns, and experiences since the last visit. It may also include information from caregivers or family members when relevant.
In psychiatry notes, the Subjective section often covers mood, anxiety levels, sleep, appetite, energy, concentration, and any distressing thoughts. It is important to document both positive and negative changes. For example, improvement in sleep but ongoing anxiety.
Quotes can be used when helpful, especially for key symptoms like suicidal thoughts or hallucinations. However, the writing should remain professional and clear. Avoid adding personal opinions in this section. Simply document what the patient reports.
Objective Section
The Objective section includes what the psychiatrist observes or measures. In psychiatry, this usually focuses on the Mental Status Examination (MSE) rather than physical findings.
Common elements in the Objective section include appearance, behavior, speech, mood and affect, thought process, thought content, perception, cognition, insight, and judgment. These observations should be factual and based on direct assessment.
Avoid vague language in this section. Instead of writing “patient seems better,” describe specific findings, such as improved eye contact or more organized speech. Clear objective data strengthens the note and supports clinical decisions.
Assessment Section
The Assessment is the clinical interpretation of the information gathered. This is where the psychiatrist explains what the findings mean. It often includes diagnoses, symptom severity, risk assessment, and clinical impressions.
In psychiatric SOAP notes, the Assessment should clearly link symptoms to diagnoses. It should also comment on progress since the last visit. For example, whether depression symptoms are improving with treatment or whether anxiety remains severe.
Risk assessment is especially important in psychiatry notes. Suicidal thoughts, self-harm, aggression, or psychosis should be clearly addressed. Even when there is no risk, documenting this explicitly is good practice.
Plan Section
The Plan section explains what will be done next. This includes medications, therapy recommendations, safety planning, follow-up timing, and patient education.
Medication plans should include the drug name, dose, frequency, and any changes made. If a medication is continued, state why. If it is changed, explain the reason clearly.
The Plan should also reflect shared decision-making. Document patient agreement, concerns, and understanding when relevant. A clear plan helps ensure continuity of care and sets expectations for both the patient and the provider.
Examples of Psychiatry Progress Note (SOAP Format)
Example 1:
Patient Name: John D.
Age: 32 years
Date: 12 Jan 2026
Diagnosis: Major Depressive Disorder, recurrent, moderate
Visit Type: Follow-up psychiatry visit
Subjective
The patient reports feeling “slightly better” since the last visit. He states that his mood has improved but he still feels low most mornings. He reports better sleep, now getting around 6–7 hours per night, compared to 4–5 hours previously. Appetite has improved, and he is eating two regular meals per day.
He denies suicidal thoughts, self-harm behaviors, or thoughts of harming others. He reports mild anxiety related to work stress but says it is manageable. He reports taking his medication daily and denies any major side effects, except for mild dry mouth.
Objective
The patient appears well-groomed and appropriately dressed. Eye contact is fair. Speech is normal in rate and tone. Mood appears mildly depressed with a congruent affect. Thought process is logical and goal-directed. No delusions or hallucinations noted.
The patient is alert and oriented to time, place, and person. Insight and judgment are fair. No psychomotor agitation or retardation observed.
Assessment
Major Depressive Disorder, recurrent, moderate. Symptoms show partial improvement since the last visit, with better sleep and appetite. Mood remains low but less severe. No current suicidal ideation or safety concerns. Medication appears to be effective and well tolerated.
Plan
Continue Sertraline 50 mg once daily. Encourage ongoing psychotherapy sessions once weekly. Provided education on stress management and sleep hygiene. Advised patient to continue medication adherence and monitor mood changes. Follow-up appointment scheduled in 4 weeks. Patient agrees with the plan and verbalizes understanding.
Example 2
Patient Name: Sarah M.
Age: 45 years
Date: 15 Jan 2026
Primary Diagnosis: Generalized Anxiety Disorder (GAD)
Secondary Diagnosis: Insomnia disorder
Visit Type: Medication management follow-up
Provider: Psychiatrist
Subjective
The patient reports ongoing anxiety but states it is “less intense” compared to the last visit. She describes daily worry related to family responsibilities and work performance. She reports feeling tense during the day and experiencing racing thoughts in the evening. She notes some improvement in sleep, now falling asleep within one hour instead of several hours.
She denies panic attacks, chest pain, or shortness of breath. She denies suicidal thoughts, self-harm, or thoughts of harming others. Appetite is stable. Energy remains low in the afternoons. She reports taking her medication as prescribed and denies dizziness, nausea, or sedation. She reports mild morning grogginess that resolves within an hour.
Objective
The patient appears calm and cooperative. She is neatly dressed with good hygiene. Eye contact is appropriate. Speech is clear, normal in rate and volume. Mood appears anxious with a mildly restricted but appropriate affect.
Thought process is linear and coherent. No delusions, hallucinations, or paranoid thoughts observed. Attention and concentration are intact during the session. The patient is alert and fully oriented to person, place, time, and situation. Insight into her condition is good, and judgment appears intact.
Assessment
Generalized Anxiety Disorder with partial improvement since the last visit. Anxiety symptoms persist but are less severe and less disruptive to daily functioning. Sleep has improved but remains inconsistent. No current safety concerns. Medication appears effective with minimal and tolerable side effects.
Plan
Continue Escitalopram 10 mg once daily. Continue sleep hygiene strategies discussed, including limiting screen use before bedtime and maintaining a consistent sleep schedule. Encourage regular physical activity and relaxation techniques such as deep breathing.
Recommend ongoing cognitive behavioral therapy sessions every two weeks. Reviewed medication benefits and potential side effects. Patient agrees with the treatment plan. Follow-up visit scheduled in 6 weeks or sooner if symptoms worsen.
Example 3
Patient Name: Sam K.
Age: 28 years
Date: 18 Jan 2026
Primary Diagnosis: Bipolar II Disorder
Current Episode: Depressive
Visit Type: Follow-up psychiatry visit
Provider: Psychiatrist
Subjective
The patient reports feeling low in mood for the past two weeks. He describes low energy, poor motivation, and difficulty completing daily tasks. He states that he feels mentally tired most of the day and has trouble concentrating at work. Sleep is irregular, with difficulty falling asleep and frequent night awakenings.
He denies current manic or hypomanic symptoms such as elevated mood, decreased need for sleep, or impulsive behavior. He denies suicidal thoughts, self-harm, or thoughts of harming others. Appetite is decreased but stable. He reports taking medications regularly and denies major side effects, though he reports mild hand tremors that do not interfere with daily activities.
Objective
The patient appears tired but cooperative. He is dressed appropriately and maintains fair eye contact. Speech is slow but clear, with normal volume. Mood appears depressed with a restricted affect. Thought process is logical and goal-directed. No hallucinations, delusions, or paranoia noted.
The patient is alert and oriented to person, place, time, and situation. Memory appears intact. Insight into illness is fair. Judgment is intact. No psychomotor agitation or abnormal movements observed during the session.
Assessment
Bipolar II Disorder, current depressive episode. The patient shows ongoing depressive symptoms with functional impairment. No evidence of hypomania or mania at this time. Mild medication side effect reported but currently tolerable. No acute safety concerns identified during this visit.
Plan
Continue Lamotrigine 100 mg once daily. Monitor mood symptoms closely. Discussed the importance of sleep routine and regular daily structure. Reviewed early warning signs of mood elevation and depression.
Encouraged ongoing psychotherapy sessions weekly. Advised patient to report worsening depression, suicidal thoughts, or mood changes immediately. Follow-up appointment scheduled in 4 weeks. Patient understands and agrees with the treatment plan.
Example 4
Patient Name: Maria L.
Age: 36 years
Date: 20 Jan 2026
Primary Diagnosis: Attention-Deficit / Hyperactivity Disorder (ADHD), adult
Visit Type: Medication follow-up
Provider: Psychiatrist
Subjective
The patient reports improved focus and attention since starting medication. She states that she is better able to complete work tasks and feels less mentally scattered during the day. She reports improved organization and time management. She still struggles with distraction in the late afternoon but feels overall progress.
She denies feeling anxious, depressed, or irritable. She denies mood swings, suicidal thoughts, or thoughts of harming others. Sleep is adequate, averaging 6–7 hours per night. Appetite is slightly reduced during the day but normal in the evening. She reports taking medication as prescribed and denies headaches, palpitations, or dizziness.
Objective
The patient appears alert and engaged throughout the session. She is neatly dressed with good hygiene. Eye contact is good. Speech is normal in rate, tone, and volume. Mood appears stable with appropriate affect.
Thought process is organized and goal-directed. No hallucinations or delusions noted. Attention and concentration appear improved during the interview. The patient is fully oriented to person, place, time, and situation. Insight and judgment are good.
Assessment
Attention-Deficit / Hyperactivity Disorder, adult type. Symptoms show improvement with current medication. Focus and task completion have improved, though mild afternoon symptoms remain. Medication is well tolerated. No safety concerns at this time.
Plan
Continue Methylphenidate 20 mg in the morning. Discussed the option of adding a small afternoon dose if symptoms persist. Encouraged use of organizational tools and structured daily routines.
Reviewed medication benefits and potential side effects. Patient agrees with the plan. Follow-up visit scheduled in 6 weeks.
Writing Clear and Effective Psychiatry Notes
Writing good psychiatry notes is a skill that improves with practice. Clear notes help psychiatrists think better, communicate better, and provide safer care. Below are key principles every psychiatrist should follow when writing psychiatric notes.
Use Simple to Understant Language
Psychiatry notes should be easy to read and easy to understand. Avoid complex sentences and unnecessary medical jargon. Simple language does not mean poor quality. It means clear thinking. Write in a way that another psychiatrist can quickly understand the patient’s condition and treatment plan. Clear words reduce confusion and prevent misinterpretation, especially in shared care settings.
Keep Each Section Focused
Each part of the psychiatry note has a specific purpose. Keeping sections separate improves structure and clarity.
- Subjective: What the patient says
- Objective: What you observe
- Assessment: What you think clinically
- Plan: What you will do next
Do not mix opinions into the Objective section. Do not repeat the same information in multiple sections. Clean structure makes notes more professional and useful.
Maintain Professional and Respectful Tone
Psychiatry notes may be read by patients, families, or legal teams. Always write respectfully and objectively. Avoid judgmental words or personal opinions. Focus on clinical facts and observations. Professional tone builds trust and protects confidentiality.
Be Specific With Symptoms
Avoid vague statements like “patient feels better” or “mood is okay.” Instead, describe symptoms with details.
Include:
- Severity (mild, moderate, severe)
- Duration (days, weeks, months)
- Frequency (daily, occasional, constant)
- Functional impact (work, relationships, sleep)
Specific details show strong clinical reasoning and support treatment decisions.
Document Risk Clearly and Consistently
Risk assessment is a critical part of psychiatry notes. Always document suicidal thoughts, self-harm, aggression, or psychotic symptoms when relevant.
If there is no risk, state it clearly. For example:
- “Patient denies suicidal or homicidal ideation.”
- “No signs of psychosis noted.”
Clear risk documentation protects both the patient and the psychiatrist.
Show Clinical Reasoning in the Assessment
The Assessment section should explain why you reached a diagnosis or decision. It should connect symptoms, history, and response to treatment.
A good assessment:
- Mentions diagnosis clearly
- Describes progress or lack of progress
- Explains changes or stability
- Notes medication response
This section reflects your expertise and clinical judgment.
Write a Clear and Actionable Plan
The Plan section should be practical and specific. It tells the next provider and the patient exactly what happens next.
Include:
- Medication name, dose, and frequency
- Therapy recommendations
- Safety planning if needed
- Follow-up timing
- Patient education
Avoid vague plans. Clear plans improve continuity of care.
Avoid Copy-Paste Errors
Copying old psychiatry notes without updating them is a common mistake. Each note should reflect the current visit.
Always review and update:
- Symptoms
- Mental status findings
- Medications
- Risk assessment
- Plan
Outdated information can lead to serious clinical and legal issues.
Stay Consistent Over Time
Consistency helps track progress and trends. Use similar wording and structure across visits while updating details.
Consistent psychiatry notes make long-term treatment easier to follow and review, especially for complex cases.
Common Mistakes in Psychiatry Notes
Writing Notes That Are Too Brief: One common mistake in psychiatry notes is writing notes that are too brief. Very short notes often miss important details such as symptom severity, changes since the last visit, functional impact, or the reasoning behind treatment decisions. When notes lack detail, it becomes harder to understand the patient’s condition and harder for other providers to continue care safely. Clear and complete notes do not need to be long, but they should always capture the key clinical information.
Copying and Pasting Old Notes Without Updates: Another frequent mistake is copying and pasting previous psychiatry notes without properly updating them. This can result in outdated symptoms, incorrect mental status findings, or old medication information remaining in the record. Notes must reflect the current visit, not past encounters. Failing to update notes can lead to clinical errors and reduces the reliability of documentation.
Mixing Subjective and Objective Information: Mixing subjective opinions into objective findings is also a common problem in psychiatry notes. The Subjective section should include what the patient reports, while the Objective section should include only observable findings such as behavior, speech, and affect. When these sections are mixed, notes become unclear and less professional. Keeping each section focused improves readability, accuracy, and overall note quality.
Final Thoughts
Psychiatry notes are more than just notes. They are a reflection of clinical thinking, patient care, and professional responsibility. Well-written psychiatric notes support better outcomes, safer care, and stronger communication. By using structured formats like the Psychiatric SOAP note, psychiatrists can write notes that are clear, consistent, and meaningful. With simple language, careful observation, and thoughtful planning, psychiatry notes become a powerful tool in mental health practice. Over time, good documentation not only helps patients but also supports the psychiatrist’s confidence, efficiency, and professional growth.
Dr. Connor Yost is an Internal Medicine resident at Creighton University School of Medicine in Arizona and an emerging leader in clinical innovation. He currently serves as Chief Medical Officer at Skriber, where he helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Dr. Yost also works as a Strategic Advisor at Doc2Doc, lending his expertise to initiatives that improve financial wellness for physicians and trainees.
His professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare. Dr. Yost is committed to building systems that allow clinicians to spend more time with patients and less on administrative tasks. Outside of medicine, he enjoys photography, entrepreneurship, and family life.
