Psychiatry Medication Management Follow-Up Note

Date of Service: [Date of Service] | Patient: [Patient full name / MRN] | Clinician: [Clinician name, credentials] | Encounter Type: [in-person / telehealth]

Chief Concern

[Patient-stated reason for follow-up, quoted when clarifying / concise clinical reason for visit]

Interval History

Since last visit on [date of prior visit], [summary of interval course for each active problem addressed today]. (Include as succinct narrative or brief bullets: symptom trajectory and timing; medication effectiveness and timing of benefit; tolerability including explicit negatives for high-stakes effects such as activation, sedation, weight changes, sexual dysfunction; adherence and any missed doses or barriers; functional status in sleep, energy, concentration, work, relationships; interval safety events including ER visits, hospitalizations, SI/self-harm, substance use changes. If any domain was not assessed, state what remains unassessed rather than leaving blank. Do not re-copy initial evaluation history.)

Objective

Vitals: [Weight / BP / Pulse as relevant] (Include only when indicated for metabolic or cardiovascular monitoring; omit line if not clinically relevant.)

Data Reviewed: [Rating scales with instrument name, score, and trend; laboratory results reviewed with dates and key values; medication reconciliation status and discrepancies addressed] (Include only data actually reviewed today.)

Mental Status Examination

• Appearance/Behavior: [brief phrase]
• Speech: [brief phrase]
• Mood / Affect: "[patient-reported mood]" / [observed affect: quality, range, congruence]
• Thought Process: [brief phrase]
• Thought Content: [denies / endorses] suicidal ideation; [denies / endorses] homicidal ideation; [if present: passive vs active, plan, intent, access to means] (Do not omit SI/HI documentation.)
• Perception: [brief phrase]
• Cognition: [orientation, attention as assessed] (Omit if not assessed and clinically appropriate.)
• Insight / Judgment: [brief phrase]

Assessment

(Provide concise clinical synthesis organized by problem. For each active diagnosis addressed, state severity and course and response to current treatment.)

[Problem 1: Diagnosis]

[Current status, course: improved / stable / worsened / partial response, relevant factors, treatment response]

[Problem 2: Diagnosis]

(Include additional problems only if addressed today.)

Risk Assessment

• Suicidal ideation: [absent / present: passive / active, with plan / intent / access to means if present]
• Homicidal ideation: [absent / present with details]
• Acute risk factors: [brief list]
• Protective factors: [brief list]
• Overall risk: Acute: [low / moderate / high]; Chronic: [low / moderate / high] (Support "low risk" with documented negatives and protective factors.)
• Risk mitigation today: [safety plan reviewed / means counseling / crisis resources provided / increased monitoring / referral / none indicated]

Plan

Medications:

• [Medication name] — [continue / start / stop / adjust] [dose] [route] [frequency]; [indication] (Include titration schedule, PRN limits, and administration instructions when applicable.)
• [Additional medications as needed]
• (If no changes: "No medication changes today.")

Monitoring: [Labs, vitals, or assessments due with timing; contingency plan for abnormal results especially for high-monitoring regimens such as lithium, clozapine, valproate] (If patient declines or cannot access monitoring, document barrier and alternative plan.)

Safety Plan: [Safety plan status, crisis resources, escalation instructions] (Include when any risk is identified; omit if no risk factors present.)

Follow-up: [Next appointment interval and modality; earlier return precautions if medication changes made]

Psychotherapy (Add-on)

(Include only if psychotherapy was provided and billed as an add-on.)

• Time: [minutes of psychotherapy]
• Modality/Interventions: [therapeutic approach and techniques used]
• Themes Addressed: [brief summary]
• Distinct from med management: [statement distinguishing from medication management time]

Total Time

Total Time: [exact minutes] on date of service (Include only if E/M level selected by time; briefly describe time-driving activities such as history, exam, counseling, care coordination, documentation.)