E/M/Psychotherapy Combined Visit Note

Date of Service: [Date]

Encounter Type: [in-person / telehealth: audio-video / telehealth: audio-only]

Participants: [Patient and others present with roles, if any]

E/M / Medical Component

Reason for Visit / Interval History: [Chief complaint, interval symptom changes since last visit, medication adherence and response, relevant side effects, and functional impacts] (Include substance use updates only when clinically relevant to medication management. If a required element was not assessed, state "Not assessed today.")

Current Medications:

• [Psychiatric medication: name, dose, frequency, adherence, response, notable side effects]
• [Additional psychiatric medications as applicable]
• [Non-psychiatric medications that materially affect prescribing decisions, if any]

Mental Status Exam: (Document only what was actually observed today; do not clone from prior notes.)

• [Appearance]
• [Behavior and psychomotor activity]
• [Speech]
• [Mood]
• [Affect]
• [Thought process]
• [Thought content]
• [Perception]
• [Cognition]
• [Insight and judgment]

Safety Assessment: (Include when any risk indicators are present; if not assessed, state "Not assessed today" with reason; omit entirely only when no risk indicators warranted assessment.)

• [Domains assessed and findings]
• [Acute risk factors and protective factors]
• [Risk level: low / moderate / high] — [brief rationale]
• [Safety interventions or plan, if applicable]

Assessment: (Problem-oriented list ordered by clinical priority.)

• [Diagnosis/Problem]: [stable / improving / worsening] — [1–2 supporting observations]
• [Additional diagnoses/problems as applicable]

E/M Plan: (Problem-oriented bullets aligned with the Assessment.)

• [Problem: medication decisions with rationale; monitoring/labs; patient education; follow-up timing]
• [Additional problems as applicable]
• [Care coordination and referrals, if any]

Psychotherapy Component

(Include this section only when psychotherapy meeting billing thresholds was provided.)

Modality: [CBT / supportive / DBT-informed / motivational interviewing / psychodynamic / other]

Focus and Interventions: [Clinical targets addressed and specific clinician interventions] (Use clinician-action language: guided, elicited, challenged, reinforced, practiced.)

Response and Progress: [Patient engagement, observable response, skill acquisition, and progress toward treatment goals; homework assigned if any]

Time / Coding Support

Psychotherapy Time: [Number] minutes of psychotherapy provided, distinct from E/M activities. (Omit if psychotherapy was less than 16 minutes; document any brief supportive counseling within the E/M narrative instead.)

E/M Basis: E/M level based on medical decision-making.