Child & Adolescent Psychiatry Follow-Up Progress Note (E/M with Psychotherapy)

Date of Service: [Date]

Setting: [in-person / telehealth] (If telehealth, note modality and patient location)

Participants: [Patient, parent/guardian, others present]

Informants: [Who provided history] (Note limited reliability if applicable)

Confidential Time: [yes / no / not applicable] (Include for adolescents; note if confidentiality limits reviewed)

Chief Complaint: [Patient/caregiver-stated reason for follow-up]

E/M Section

Interval History: [Changes in psychiatric symptoms since last visit, including severity, frequency, and functional impact. Note functioning across relevant domains (school, peers, family, sleep). Include medication adherence, perceived benefit, and side effects. Attribute information to sources when accounts differ.]

Safety Screening: [Suicidal ideation, self-harm/NSSI, homicidal ideation, access to lethal means] (If concerns present, document risk and protective factors in detail. If not assessed, state reason.)

Mental Status Exam: [Appearance/behavior, speech, mood, affect, thought process, thought content including SI/HI, perception, cognition, insight, judgment] (Note telehealth limitations if applicable)

Assessment:

[Active psychiatric diagnoses with severity/specifiers as applicable]

Clinical Formulation: [2–4 sentence synthesis of current status versus baseline, contributing factors, and treatment response]

Risk Level: [low / moderate / high] with rationale and disposition decision (Include when safety concerns present or recently assessed)

Plan:

• Medications: [Continue/start/adjust/discontinue with rationale; informed consent points discussed; monitoring plan] (Document black box warning discussion and metabolic/cardiac risk counseling when applicable)
• Safety Interventions: [Safety plan updates, means restriction counseling, crisis resources] (Include when indicated)
• Care Coordination: [Communications with therapist, PCP, school, or other providers] (Include when applicable)
• Follow-Up: [Return interval and parameters for earlier return]

Psychotherapy Section

(Include only if psychotherapy provided for 16+ minutes. If not provided, state: "Psychotherapy was not provided this visit.")

Session: [Modality/approach]; [Format: individual / family / dyadic]; [Participants]

Focus: [1–3 therapeutic targets tied to diagnoses or treatment goals]

Interventions: [Specific techniques used—describe what was done, not just what was discussed]

Response: [Patient/family engagement, skill acquisition, movement toward goals, barriers encountered]

Psychotherapy Time: [Exact minutes] (This time is separate from and not included in E/M time.)

Next Steps: [Specific homework assignment]; [Focus for next session]