Spravato, MAT, defensible notes, AriaMD setup, PHQ-9 and GAD-7. Written by clinicians on the team.
Therapist and prescriber notes should each stand alone: own the work you did, name the other clinician, and document the handoff without cloning the other chart.
Open guideA MAT follow-up sequence: last use, cravings, UDS plus your response, naloxone in the home, dose decision, and next toxicology. Not the 2026 intake spec.
MAOI starts need a dated washout from the outgoing serotonergic drug, diet and interaction counseling, the first dose, and a fast follow-up.
Build the six Stanley-Brown steps in the patient's words after a risk assessment. Chart means restriction, copies, and the review date.
Chart reproductive status, the drug-specific talk, alternatives, the patient's choice, and the monitoring plan. Do not hide this in a checkbox.
After the clozapine REMS ended in 2025, ANC monitoring still belongs in the chart: result, interval, dose decision, and neutropenia counseling.
Prior-auth clinicals win on failed trials with dates and doses, scale severity, contraindications, and the site of care. This is not the session note.
A benzo taper note states why now, the current dose and duration, the written reduction, withdrawal and seizure risk, and the rescue rules.
Adult stimulant starts need the ADHD diagnosis basis, baseline BP/HR, cardiac screen, PDMP, diversion counseling, days supply, and a short follow-up.
Pick MDM or total time before you code. If 90833/90836/90838 is on the claim, MDM is mandatory. Write the basis you used.
90833 needs separately identifiable psychotherapy minutes (16-37), content, and an E/M selected by MDM. One combined time stamp fails.
Lithium follow-up is the trough, the renal and thyroid trend, side effects, interacting meds, and a dose decision that cites those numbers.
Session-by-session TMS charting: 90867 vs 90868 vs 90869, motor threshold, parameters, side effects, and PHQ-9 course trend.
How to chart a polypharmacy, partial-response med-management visit: interval history, regimen list, assessment reasoning, and plan.
REMS-aware Spravato documentation: pre-session checks, vitals timepoints, observation, discharge criteria, and a sample template.
What 2026 MAT notes need for buprenorphine, methadone, and naltrexone: intake fields, per-visit items, UDS, and 42 CFR Part 2 handling.
How to edit an AI draft so it does not read as templated: prune filler, vary phrasing, own the assessment, and attest on sign-off.
When to give the C-SSRS, how to score and chart it, and assessment language that holds up if a visit becomes a sentinel event.
When to give PHQ-9 and GAD-7, how to score and trend them, and how to keep scores structured for MBC reporting.
What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR.
Medical necessity is the right signal, not a long note. How to chart S, O, A, and P so a reviewer can follow the visit.
Review E/M codes 99213-99215, add-on codes 90833, 90836, and 90838, and standalone codes 90834 and 90837.
Build the six Stanley-Brown steps in the patient's words after a risk assessment. Chart means restriction, copies, and the review date.
90846 and 90847 are family psychotherapy. Chart who attended, what you did with the family, and keep other people's treatment out of this record.
Missed visits are outreach notes, not phantom 90834s. Chart the miss, the safety check, the policy, and why the next session is still necessary.
90853 group notes need a shared session block plus a unique per-member participation, response, and risk update. Copy-paste is the audit.
DAP notes fail audits when Data is a recap and Assessment is a mood word. Name the intervention, the response, and the treatment-plan goal.
How to edit an AI draft so it does not read as templated: prune filler, vary phrasing, own the assessment, and attest on sign-off.
When to give the C-SSRS, how to score and chart it, and assessment language that holds up if a visit becomes a sentinel event.
When to give PHQ-9 and GAD-7, how to score and trend them, and how to keep scores structured for MBC reporting.
What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR.
Medical necessity is the right signal, not a long note. How to chart S, O, A, and P so a reviewer can follow the visit.
A MAT follow-up sequence: last use, cravings, UDS plus your response, naloxone in the home, dose decision, and next toxicology. Not the 2026 intake spec.
MAOI starts need a dated washout from the outgoing serotonergic drug, diet and interaction counseling, the first dose, and a fast follow-up.
Build the six Stanley-Brown steps in the patient's words after a risk assessment. Chart means restriction, copies, and the review date.
Chart reproductive status, the drug-specific talk, alternatives, the patient's choice, and the monitoring plan. Do not hide this in a checkbox.
After the clozapine REMS ended in 2025, ANC monitoring still belongs in the chart: result, interval, dose decision, and neutropenia counseling.
A benzo taper note states why now, the current dose and duration, the written reduction, withdrawal and seizure risk, and the rescue rules.
Adult stimulant starts need the ADHD diagnosis basis, baseline BP/HR, cardiac screen, PDMP, diversion counseling, days supply, and a short follow-up.
Pick MDM or total time before you code. If 90833/90836/90838 is on the claim, MDM is mandatory. Write the basis you used.
90833 needs separately identifiable psychotherapy minutes (16-37), content, and an E/M selected by MDM. One combined time stamp fails.
Lithium follow-up is the trough, the renal and thyroid trend, side effects, interacting meds, and a dose decision that cites those numbers.
Session-by-session TMS charting: 90867 vs 90868 vs 90869, motor threshold, parameters, side effects, and PHQ-9 course trend.
How to chart a polypharmacy, partial-response med-management visit: interval history, regimen list, assessment reasoning, and plan.
REMS-aware Spravato documentation: pre-session checks, vitals timepoints, observation, discharge criteria, and a sample template.
What 2026 MAT notes need for buprenorphine, methadone, and naltrexone: intake fields, per-visit items, UDS, and 42 CFR Part 2 handling.
How to edit an AI draft so it does not read as templated: prune filler, vary phrasing, own the assessment, and attest on sign-off.
When to give the C-SSRS, how to score and chart it, and assessment language that holds up if a visit becomes a sentinel event.
When to give PHQ-9 and GAD-7, how to score and trend them, and how to keep scores structured for MBC reporting.
What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR.
Medical necessity is the right signal, not a long note. How to chart S, O, A, and P so a reviewer can follow the visit.
Review E/M codes 99213-99215, add-on codes 90833, 90836, and 90838, and standalone codes 90834 and 90837.
Missed visits are outreach notes, not phantom 90834s. Chart the miss, the safety check, the policy, and why the next session is still necessary.
Prior-auth clinicals win on failed trials with dates and doses, scale severity, contraindications, and the site of care. This is not the session note.
Pick MDM or total time before you code. If 90833/90836/90838 is on the claim, MDM is mandatory. Write the basis you used.
90853 group notes need a shared session block plus a unique per-member participation, response, and risk update. Copy-paste is the audit.
A five-day plan for a small group: workspace setup, provider invites, templates, automations, and the week-one metrics that predict adoption.
What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR.
Review E/M codes 99213-99215, add-on codes 90833, 90836, and 90838, and standalone codes 90834 and 90837.
Audio-only Medicare visits need modifier 93, home location, and why video was not used. Capability and consent belong in the header, not a later addendum.
A five-day checklist: what to correct, what to template, and the settings that stop the same edit from repeating.
POS 10 is the patient's home. POS 02 is telehealth somewhere else. Match location, consent, and modifier 95 or 93 in the same header.
Name who was in the visit, in what role, in what language or modality, and which words belong to the patient vs a collateral.
Build a Nextvisit intake template: editor path, variable tokens, required sections, and when to split into a second template.
What 42 CFR Part 2 requires for SUD records: who it covers, consent, segregation, disclosure logs, and how it changes the workspace.
What a psychiatry AI scribe has to capture: DSM-5 templates, live notes, HIPAA handling, EHR export, and audit-ready outcomes.
Evaluate psychiatry AI scribes for specialty templates, risk language, and session-to-session context.
If a workflow is missing, send a note. We write guides from onboarding questions.