Telepsychiatry Visit Note (Audio/Video)

Date of Service: [date of encounter]

Patient: [full name, DOB, MRN as available]

Clinician: [name, credentials]

Visit Type: [initial evaluation / follow-up / psychotherapy / combined E/M + psychotherapy]

Modality: [audio-video / audio-only] (If audio-only, document reason video was not used.)

Platform: [telehealth platform name]

Patient Location: [city, state at minimum; full address preferred for emergency access]

Emergency Contact: [name, relationship, phone]

Disconnection Plan: [who calls whom, what number, escalation if safety concern]

Consent: [brief attestation that patient consented to telehealth services]

Chief Complaint / History

[Reason for visit and current concerns] (Begin with the chief complaint. For established patients, summarize symptom trajectory since last contact, functional impact, treatment adherence and response, side effects, and relevant interval events. Do not infer denials unless directly asked and answered; if a domain was not assessed, state "Not assessed.")

[Background and pertinent history] (For initial evaluations, include presenting symptoms with timeline and prior treatment history. Incorporate pertinent psychiatric, medical, substance use, social, and family history as clinically relevant. For established patients with no interval changes, state "Background reviewed, unchanged.")

Mental Status Examination

(If audio-only modality, explicitly note which elements could not be assessed and impact on assessment confidence.)

• Appearance/Behavior: [grooming, psychomotor activity, cooperativeness]
• Speech: [rate, volume, articulation, spontaneity]
• Mood/Affect: [mood (patient report); affect (observed range, congruence, stability)]
• Thought Process: [organization, goal-directedness, associations]
• Thought Content: [SI/HI, delusions, obsessions, preoccupations] (Specify passive vs. active, plan, intent when applicable.)
• Perceptions: [hallucinations, illusions, derealization/depersonalization]
• Cognition: [orientation, attention, memory, concentration] (State "Not assessed" for domains not evaluated.)
• Insight/Judgment: [awareness of illness, decision-making capacity]

Risk Assessment

(Document current suicidal and homicidal ideation status, access to lethal means, risk and protective factors, and clinical risk stratification with rationale. When meaningful risk is present, include safety plan elements. Ensure consistency with the emergency/disconnection plan in the header.)

• Suicidal Ideation: [none / passive / active] [plan, intent, details as applicable]
• Homicidal Ideation: [none / passive / active] [plan, intent, details as applicable]
• Access to Lethal Means: [firearms, medications, other; means safety steps taken]
• Risk Factors: [salient clinical, historical, psychosocial factors]
• Protective Factors: [supports, coping skills, reasons for living, treatment engagement]
• Risk Stratification: [low / moderate / high] with rationale
• Safety Plan: [warning signs, coping strategies, supports, crisis resources, means restriction] (Include only if meaningful risk is present.)

Assessment

[Diagnoses and clinical formulation] (List problems/diagnoses in descending order of acuity with brief supporting evidence. Include differential diagnoses when relevant. For established patients, note treatment response and progress toward goals.)

Plan

• Medications: [medication changes with dose, rationale, risks discussed, monitoring plan] (For controlled substances, include indication, PDMP review, and risk mitigation.)
• Therapy: [modality, session focus, patient response, psychotherapy minutes if billing requires] (Include only if psychotherapy provided.)
• Coordination: [collateral contacts, referrals, ROI status] (Include only if applicable.)
• Follow-up: [date, modality, contingency if telehealth becomes clinically inappropriate]