Telepsychiatry Visit Note (Child & Adolescent Psychiatry)

Date/Time Zone: [Service date and local time zone]

Patient: [Full name], MRN: [MRN], DOB: [DOB], Age: [Age]

Provider: [Name], [Credentials]

Visit Type: [follow-up / urgent / medication management / psychotherapy / combined]

Modality: [audio-video / audio-only] via [Platform] (Note connection quality issues only if they meaningfully affected assessment.)

Participants: [Names with roles and relationships] (Note segmented presence if visit was split between caregiver and adolescent portions.)

Telehealth Compliance & Safety

(If any safety-critical element is unavailable, document what is missing, why, whether the visit proceeded, and what mitigation occurred. Do not leave required fields blank without explanation.)

Patient Location: [Physical address or city/state], [home / school / other] (If location cannot be confirmed, state this explicitly and document disposition.)

Identity Verification: [Method used for patient and guardian verification]

Consent & Custody: [Telehealth consent status], [Treatment consent from legal guardian], [Youth assent status], [Decision-making authority if shared or restricted]

Privacy Check: [Private setting confirmed / not confirmed], [Others present or off-camera], [Headphones used for confidential segments: yes / no]

Emergency Plan:

• Dispatch Address: [Address for emergency response]
• Local Emergency Contact: [Name], [Relationship], [Phone], [authorized / not authorized]
• Disconnection Plan: [Plan if disconnected during elevated risk]

Assessment Limitations: [Telehealth-specific constraints affecting evaluation] (If none, state "None identified.")

History of Present Illness

[Chief complaint or reason for visit]. Informant(s): [patient / caregiver / collateral sources]. [Note discrepancies between informants if present.]

[Interval symptom course since last visit], [Treatment response and medication adherence], [Side effects], [Functional status across home, school, and peer domains], [Relevant stressors or supports].

[Brief safety update: self-harm, suicidal thoughts, aggression, substance use since last contact]. Confidential adolescent segment: [conducted / not conducted]. (If conducted, summarize only clinically necessary content; avoid sensitive specifics that could pose safety risks if disclosed via portal.)

Mental Status Exam

(Document only what was observed. Omit elements that could not be assessed.)

• Appearance/Grooming: [Observations via video]
• Behavior/Psychomotor: [Observations]
• Speech: [Rate, volume, articulation]
• Mood: [Patient-stated mood]
• Affect: [Range, reactivity, congruence]
• Thought Process: [Organization, coherence]
• Thought Content: [Suicidal ideation / homicidal ideation / delusions / obsessions as applicable]
• Perceptions: [Hallucinations or none reported]
• Attention/Concentration: [Observations]
• Insight/Judgment: [Assessment]
• Telehealth Limitations: [Specific MSE constraints, e.g., camera placement affecting eye contact assessment] (Include only if applicable.)

Risk Assessment & Safety Plan

Suicide/Self-Harm Risk

• Ideation: [present / absent]; [frequency, intensity, duration if present]
• Intent: [present / absent]
• Plan: [present / absent]; [details if present]
• Means Access: [details]; [means safety steps taken]
• Recent Self-Harm: [Describe or deny]
• Protective Factors: [Supports, reasons for living, treatment engagement]
• Overall Risk Level: [low / moderate / high] over [timeframe]

Violence/Aggression Risk

• Homicidal Ideation/Threats: [present / absent]; [details if present]
• Recent Aggression: [Describe or deny]
• Weapon Access: [yes / no]; [details]

Safety Plan

• Coping Strategies: [Skills and strategies discussed]
• Supervision Plan: [Caregiver monitoring arrangements]
• Means Safety Counseling: [Medications, firearms, sharps secured]
• Crisis Resources Provided: [988, local crisis line, ER, mobile crisis]
• Caregiver Agreement: [confirmed / not confirmed]

(If elevated risk, document how telehealth constraints affected disposition decisions.)

Abuse/Neglect: [Concerns and mandatory reporting actions taken / no concerns identified] (Include details only if concerns present.)

Assessment & Plan

(Organize problems from highest to lowest acuity.)

[Problem 1]: [Working diagnosis]

[Current status/severity] — [Brief supporting evidence]

• Medications: [Action: start / continue / adjust / discontinue], [Name, dose, frequency], [Rationale], [Monitoring plan]
• Therapy/Psychosocial: [Modality, referrals, goals]
• School/System: [Accommodations, IEP/504, agency coordination] (Include only if applicable.)
• Care Coordination: [Collaboration with therapist, PCP, school; referrals; releases]
• Shared Decision-Making: [Risks/benefits/alternatives discussed], [Youth and caregiver preferences], [How disagreements were addressed]

[Problem 2]: [Working diagnosis]

(Include additional problems as clinically indicated, using same format.)

Follow-Up: [Timeframe], [audio-video / audio-only / in-person]. In-Person Required If: [Conditions necessitating in-person evaluation]. Safety Precautions: [Return instructions for worsening symptoms, safety concerns, adverse effects]. Crisis Contacts: 988, [local crisis line], [ER/mobile crisis].