Inpatient Psychiatry Daily Progress Note

Header

Date/Time: [Date and time of note entry]
Service/Unit/Bed: [Service / unit / bed]
Hospital Day: [Hospital day number]
Legal Status: [voluntary / involuntary-hold type / court status]
Attending/Author: [Attending name / Author name, credentials]
Information Sources: [patient interview / nursing / chart / collateral] (List all sources used; if patient unavailable, specify alternative sources.)

Subjective

[Chief concern for today] (Begin with the patient's stated primary concern if available; use brief direct quotes only for mood or safety-relevant content.)

• [Overnight/interval events] (Agitation, de-escalation, PRNs given with indication and effect, sleep quality per staff/patient.)
• [Patient-reported symptoms and trajectory] (Mood, anxiety, psychosis, mania, or other symptom changes since last note.)
• [Medication adherence and refusals] (Include reasons for refusals if stated.)
• [Side effects assessed] (If not assessed, state "not assessed today.")
• [Collateral updates] (Nursing, social work, family—include only new and relevant information.)
• [Engagement/participation] (Group attendance, milieu participation, ADLs as relevant.)

(If patient cannot participate in interview, document why and which alternative sources were used.)

Objective

Vitals/Weight: [Relevant vitals and weight] (Include especially for medication changes, detox, or metabolic monitoring.)

Current Psych Meds: [Scheduled psychiatric medications with doses] (Note PRNs used in past 24 hours with indication and effect; highlight changes initiated today.)

Labs/Studies: [New results and relevant pending tests] (Omit if none relevant today.)

Mental Status Exam

• Appearance/Behavior: [Grooming, eye contact, motor activity, cooperation]
• Speech: [Rate, volume, tone, fluency, latency]
• Mood: [Patient-reported mood] (Use brief quote if provided.)
• Affect: [Range, intensity, reactivity, congruence]
• Thought Process: [Organization, coherence, associations]
• Thought Content: [Delusions, preoccupations; SI/HI inquiry documented explicitly] (Do not document "denies SI/HI" unless explicitly asked.)
• Perception: [Hallucinations or perceptual disturbances] (State "assessed" or "not assessed.")
• Cognition: [Alertness, orientation, attention as assessed]
• Insight: [Description]
• Judgment/Impulse Control: [Description]

(If any domain cannot be assessed, explicitly state the reason.)

Risk & Safety

Suicide/Self-Harm: [Screening tool result if used] [Suicide inquiry: ideation type, plan, intent, means, recent behaviors, acute drivers, protective factors] [Risk formulation: acute-on-chronic low / moderate / high with rationale] (If patient refuses, document refusal and use behavioral/collateral data.)

Violence/Aggression: [HI assessment, recent aggression on unit, impulsivity, relevant triggers]

Other Risks: [Elopement, grave disability, medical deterioration] (Include only if applicable.)

Current Precautions: [Observation level, restrictions, contraband/sharps/ligature precautions] (Note changes since yesterday with rationale.)

Assessment & Plan

[Synthesis] (1–3 sentence summary: primary diagnosis, clinical trajectory [improved / unchanged / worsened], and current barriers.)

• Safety: [Observation level with rationale; de-escalation plan; PRN strategy; escalation protocol if needed]
• Psychopharmacology: [Continue / adjust / hold / stop with rationale and target symptoms; monitoring plan; side effect management]
• Therapy/Milieu: [Group recommendations, skills focus, behavioral activation, psychoeducation]
• Substance Use: [Withdrawal management, cravings, SUD medications, linkage] (Include only if applicable.)
• Medical: [Active medical issues, consults, monitoring] (Include only if applicable.)
• Legal/Administrative: [Hold status changes, capacity evaluations, hearing dates] (Include only if applicable.)
• Disposition: [Anticipated discharge destination; barriers; discharge criteria; estimated timeframe; follow-up needs; task owners]

(If information is missing, document what was not assessed rather than implying absence. For restraint or seclusion events, enter a separate time-stamped addendum per institutional policy.)