--- title: Guides | Nextvisit description: Guides for behavioral health documentation cover Spravato, MAT, defensible psychiatric notes, AriaMD setup, and PHQ-9 and GAD-7 scoring. url: "https://nextvisit.ai/guides" type: static generatedAt: "2026-09-21T03:14:00.052Z" --- Playbooks # How-tos for behavioral health documentation. Spravato, MAT, defensible notes, AriaMD setup, PHQ-9 and GAD-7. Written by clinicians on the team. [Latest playbook ## How to document split treatment so both charts hold 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. Therapists · Psychiatrists · NPs and PAs 5 min Updated Sep 2026 Open guide](/guides/how-to-document-split-treatment) 1. [### How to document naloxone, last use, and UDS in a MAT follow-up 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. - NPs and PAs 4 min · Updated Aug 2026](/guides/how-to-document-naloxone-last-use-and-uds-in-mat) 1. [### How to document an MAOI washout and the next start MAOI starts need a dated washout from the outgoing serotonergic drug, diet and interaction counseling, the first dose, and a fast follow-up. - NPs and PAs 4 min · Updated Aug 2026](/guides/how-to-document-an-maoi-washout) 1. [### How to write and chart a Stanley-Brown safety plan in the visit Build the six Stanley-Brown steps in the patient's words after a risk assessment. Chart means restriction, copies, and the review date. - Therapists - NPs and PAs 5 min · Updated Aug 2026](/guides/how-to-chart-a-stanley-brown-safety-plan) 1. [### How to document pregnancy counseling for a psychotropic Chart reproductive status, the drug-specific talk, alternatives, the patient's choice, and the monitoring plan. Do not hide this in a checkbox. - NPs and PAs 4 min · Updated Aug 2026](/guides/how-to-document-pregnancy-counseling-for-a-psychotropic) 1. [### How to document clozapine and ANC monitoring After the clozapine REMS ended in 2025, ANC monitoring still belongs in the chart: result, interval, dose decision, and neutropenia counseling. - NPs and PAs 5 min · Updated Aug 2026](/guides/how-to-document-clozapine-anc-monitoring) 1. [### How to write a Spravato or TMS prior-auth clinical 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. - Administrators 5 min · Updated Jul 2026](/guides/how-to-write-a-spravato-or-tms-prior-auth) 1. [### How to document a benzodiazepine taper A benzo taper note states why now, the current dose and duration, the written reduction, withdrawal and seizure risk, and the rescue rules. - NPs and PAs 4 min · Updated Jul 2026](/guides/how-to-document-a-benzodiazepine-taper) 1. [### How to document a first adult stimulant start Adult stimulant starts need the ADHD diagnosis basis, baseline BP/HR, cardiac screen, PDMP, diversion counseling, days supply, and a short follow-up. - NPs and PAs 5 min · Updated Jun 2026](/guides/how-to-document-a-first-adult-stimulant-start) 1. [### How to choose time-based vs MDM for a psych E/M 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. - NPs and PAs - Administrators 4 min · Updated Jun 2026](/guides/how-to-choose-time-based-vs-mdm-for-psych-em) 1. [### How to document 90833 add-on psychotherapy on a med visit 90833 needs separately identifiable psychotherapy minutes (16-37), content, and an E/M selected by MDM. One combined time stamp fails. - NPs and PAs 4 min · Updated Jun 2026](/guides/how-to-document-90833-add-on-psychotherapy) 1. [### How to run and chart a lithium monitoring visit Lithium follow-up is the trough, the renal and thyroid trend, side effects, interacting meds, and a dose decision that cites those numbers. - NPs and PAs 5 min · Updated May 2026](/guides/how-to-chart-a-lithium-monitoring-visit) 1. [### How to document a TMS session Session-by-session TMS charting: 90867 vs 90868 vs 90869, motor threshold, parameters, side effects, and PHQ-9 course trend. - NPs and PAs 5 min · Updated May 2026](/guides/how-to-document-a-tms-session) 1. [### Documenting a complex outpatient psychiatric medication management visit How to chart a polypharmacy, partial-response med-management visit: interval history, regimen list, assessment reasoning, and plan. - NPs and PAs 4 min · Updated May 2026](/guides/complex-psych-medication-management-visit) 1. [### Documenting a Spravato session step-by-step REMS-aware Spravato documentation: pre-session checks, vitals timepoints, observation, discharge criteria, and a sample template. - NPs and PAs 3 min · Updated Apr 2026](/guides/spravato-session-documentation) 1. [### MAT note requirements 2026 What 2026 MAT notes need for buprenorphine, methadone, and naltrexone: intake fields, per-visit items, UDS, and 42 CFR Part 2 handling. - NPs and PAs 4 min · Updated Apr 2026](/guides/mat-note-requirements-2026) 1. [### Writing defensible psychiatric notes with AI in the room 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. - NPs and PAs - Therapists 4 min · Updated Apr 2026](/guides/defensible-psych-notes-ai) 1. [### C-SSRS scoring and risk documentation 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. - NPs and PAs - Therapists 4 min · Updated Mar 2026](/guides/cssrs-risk-documentation) 1. [### PHQ-9 and GAD-7 scoring and trend documentation When to give PHQ-9 and GAD-7, how to score and trend them, and how to keep scores structured for MBC reporting. - Therapists - NPs and PAs 3 min · Updated Mar 2026](/guides/phq9-gad7-best-practices) 1. [### What a psychiatric timeline should hold What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR. - NPs and PAs - Therapists - Administrators 2 min read · Updated Dec 2025](/guides/building-patient-timelines-for-better-psychiatric-care) 1. [### Psychiatry SOAP notes that support medical necessity 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. - NPs and PAs - Therapists 4 min read · Updated Dec 2025](/guides/psych-soap-notes-that-prove-medical-necessity) 1. [### Reviewing mental health service codes Review E/M codes 99213-99215, add-on codes 90833, 90836, and 90838, and standalone codes 90834 and 90837. - Administrators - NPs and PAs 4 min read · Updated Nov 2025](/guides/ai-compliant-upcoding-mental-health-revenue) 1. [### How to write and chart a Stanley-Brown safety plan in the visit Build the six Stanley-Brown steps in the patient's words after a risk assessment. Chart means restriction, copies, and the review date. - Psychiatrists - NPs and PAs 5 min · Updated Aug 2026](/guides/how-to-chart-a-stanley-brown-safety-plan) 1. [### How to document a family or collateral session without turning it into the identified patient's therapy note 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. 4 min · Updated Jul 2026](/guides/how-to-document-a-family-collateral-session) 1. [### How to document a no-show, late cancel, and the next medically necessary visit Missed visits are outreach notes, not phantom 90834s. Chart the miss, the safety check, the policy, and why the next session is still necessary. - Administrators 4 min · Updated Jul 2026](/guides/how-to-document-a-no-show-and-the-next-visit) 1. [### How to document a group therapy session for billing 90853 group notes need a shared session block plus a unique per-member participation, response, and risk update. Copy-paste is the audit. - Administrators 4 min · Updated May 2026](/guides/how-to-document-a-group-therapy-session-for-billing) 1. [### How to write a DAP note that still shows medical necessity 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. 4 min · Updated May 2026](/guides/how-to-write-a-dap-note-that-shows-medical-necessity) 1. [### Writing defensible psychiatric notes with AI in the room 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. - Psychiatrists - NPs and PAs 4 min · Updated Apr 2026](/guides/defensible-psych-notes-ai) 1. [### C-SSRS scoring and risk documentation 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. - Psychiatrists - NPs and PAs 4 min · Updated Mar 2026](/guides/cssrs-risk-documentation) 1. [### PHQ-9 and GAD-7 scoring and trend documentation When to give PHQ-9 and GAD-7, how to score and trend them, and how to keep scores structured for MBC reporting. - NPs and PAs - Psychiatrists 3 min · Updated Mar 2026](/guides/phq9-gad7-best-practices) 1. [### What a psychiatric timeline should hold What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR. - Psychiatrists - NPs and PAs - Administrators 2 min read · Updated Dec 2025](/guides/building-patient-timelines-for-better-psychiatric-care) 1. [### Psychiatry SOAP notes that support medical necessity 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. - Psychiatrists - NPs and PAs 4 min read · Updated Dec 2025](/guides/psych-soap-notes-that-prove-medical-necessity) 1. [### How to document naloxone, last use, and UDS in a MAT follow-up 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. - Psychiatrists 4 min · Updated Aug 2026](/guides/how-to-document-naloxone-last-use-and-uds-in-mat) 1. [### How to document an MAOI washout and the next start MAOI starts need a dated washout from the outgoing serotonergic drug, diet and interaction counseling, the first dose, and a fast follow-up. - Psychiatrists 4 min · Updated Aug 2026](/guides/how-to-document-an-maoi-washout) 1. [### How to write and chart a Stanley-Brown safety plan in the visit Build the six Stanley-Brown steps in the patient's words after a risk assessment. Chart means restriction, copies, and the review date. - Psychiatrists - Therapists 5 min · Updated Aug 2026](/guides/how-to-chart-a-stanley-brown-safety-plan) 1. [### How to document pregnancy counseling for a psychotropic Chart reproductive status, the drug-specific talk, alternatives, the patient's choice, and the monitoring plan. Do not hide this in a checkbox. - Psychiatrists 4 min · Updated Aug 2026](/guides/how-to-document-pregnancy-counseling-for-a-psychotropic) 1. [### How to document clozapine and ANC monitoring After the clozapine REMS ended in 2025, ANC monitoring still belongs in the chart: result, interval, dose decision, and neutropenia counseling. - Psychiatrists 5 min · Updated Aug 2026](/guides/how-to-document-clozapine-anc-monitoring) 1. [### How to document a benzodiazepine taper A benzo taper note states why now, the current dose and duration, the written reduction, withdrawal and seizure risk, and the rescue rules. - Psychiatrists 4 min · Updated Jul 2026](/guides/how-to-document-a-benzodiazepine-taper) 1. [### How to document a first adult stimulant start Adult stimulant starts need the ADHD diagnosis basis, baseline BP/HR, cardiac screen, PDMP, diversion counseling, days supply, and a short follow-up. - Psychiatrists 5 min · Updated Jun 2026](/guides/how-to-document-a-first-adult-stimulant-start) 1. [### How to choose time-based vs MDM for a psych E/M 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. - Psychiatrists - Administrators 4 min · Updated Jun 2026](/guides/how-to-choose-time-based-vs-mdm-for-psych-em) 1. [### How to document 90833 add-on psychotherapy on a med visit 90833 needs separately identifiable psychotherapy minutes (16-37), content, and an E/M selected by MDM. One combined time stamp fails. - Psychiatrists 4 min · Updated Jun 2026](/guides/how-to-document-90833-add-on-psychotherapy) 1. [### How to run and chart a lithium monitoring visit Lithium follow-up is the trough, the renal and thyroid trend, side effects, interacting meds, and a dose decision that cites those numbers. - Psychiatrists 5 min · Updated May 2026](/guides/how-to-chart-a-lithium-monitoring-visit) 1. [### How to document a TMS session Session-by-session TMS charting: 90867 vs 90868 vs 90869, motor threshold, parameters, side effects, and PHQ-9 course trend. - Psychiatrists 5 min · Updated May 2026](/guides/how-to-document-a-tms-session) 1. [### Documenting a complex outpatient psychiatric medication management visit How to chart a polypharmacy, partial-response med-management visit: interval history, regimen list, assessment reasoning, and plan. - Psychiatrists 4 min · Updated May 2026](/guides/complex-psych-medication-management-visit) 1. [### Documenting a Spravato session step-by-step REMS-aware Spravato documentation: pre-session checks, vitals timepoints, observation, discharge criteria, and a sample template. - Psychiatrists 3 min · Updated Apr 2026](/guides/spravato-session-documentation) 1. [### MAT note requirements 2026 What 2026 MAT notes need for buprenorphine, methadone, and naltrexone: intake fields, per-visit items, UDS, and 42 CFR Part 2 handling. - Psychiatrists 4 min · Updated Apr 2026](/guides/mat-note-requirements-2026) 1. [### Writing defensible psychiatric notes with AI in the room 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. - Psychiatrists - Therapists 4 min · Updated Apr 2026](/guides/defensible-psych-notes-ai) 1. [### C-SSRS scoring and risk documentation 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. - Psychiatrists - Therapists 4 min · Updated Mar 2026](/guides/cssrs-risk-documentation) 1. [### PHQ-9 and GAD-7 scoring and trend documentation When to give PHQ-9 and GAD-7, how to score and trend them, and how to keep scores structured for MBC reporting. - Therapists - Psychiatrists 3 min · Updated Mar 2026](/guides/phq9-gad7-best-practices) 1. [### What a psychiatric timeline should hold What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR. - Psychiatrists - Therapists - Administrators 2 min read · Updated Dec 2025](/guides/building-patient-timelines-for-better-psychiatric-care) 1. [### Psychiatry SOAP notes that support medical necessity 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. - Psychiatrists - Therapists 4 min read · Updated Dec 2025](/guides/psych-soap-notes-that-prove-medical-necessity) 1. [### Reviewing mental health service codes Review E/M codes 99213-99215, add-on codes 90833, 90836, and 90838, and standalone codes 90834 and 90837. - Administrators - Psychiatrists 4 min read · Updated Nov 2025](/guides/ai-compliant-upcoding-mental-health-revenue) 1. [### How to document a no-show, late cancel, and the next medically necessary visit Missed visits are outreach notes, not phantom 90834s. Chart the miss, the safety check, the policy, and why the next session is still necessary. - Therapists 4 min · Updated Jul 2026](/guides/how-to-document-a-no-show-and-the-next-visit) 1. [### How to write a Spravato or TMS prior-auth clinical 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. - Psychiatrists 5 min · Updated Jul 2026](/guides/how-to-write-a-spravato-or-tms-prior-auth) 1. [### How to choose time-based vs MDM for a psych E/M 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. - Psychiatrists - NPs and PAs 4 min · Updated Jun 2026](/guides/how-to-choose-time-based-vs-mdm-for-psych-em) 1. [### How to document a group therapy session for billing 90853 group notes need a shared session block plus a unique per-member participation, response, and risk update. Copy-paste is the audit. - Therapists 4 min · Updated May 2026](/guides/how-to-document-a-group-therapy-session-for-billing) 1. [### Onboarding a 5-provider group practice in week one A five-day plan for a small group: workspace setup, provider invites, templates, automations, and the week-one metrics that predict adoption. 4 min · Updated Feb 2026](/guides/onboarding-five-provider-group-week-one) 1. [### What a psychiatric timeline should hold What a psychiatric timeline should hold (scales, meds, diagnoses, session context) and how to add one without replacing the EHR. - Psychiatrists - NPs and PAs - Therapists 2 min read · Updated Dec 2025](/guides/building-patient-timelines-for-better-psychiatric-care) 1. [### Reviewing mental health service codes Review E/M codes 99213-99215, add-on codes 90833, 90836, and 90838, and standalone codes 90834 and 90837. - Psychiatrists - NPs and PAs 4 min read · Updated Nov 2025](/guides/ai-compliant-upcoding-mental-health-revenue) 1. [### How to document audio-only Medicare behavioral health visits 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. 4 min · Updated Sep 2026](/guides/how-to-document-audio-only-medicare-behavioral-health) 1. [### Setting up your AriaMD voice in week one A five-day checklist: what to correct, what to template, and the settings that stop the same edit from repeating. 3 min · Updated Sep 2026](/guides/ariamd-voice-week-one) 1. [### How to chart POS 10 vs 02 and telehealth consent in the note 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. 4 min · Updated Jun 2026](/guides/how-to-chart-pos-10-vs-02-and-telehealth-consent) 1. [### How to document interpreter or collateral participation Name who was in the visit, in what role, in what language or modality, and which words belong to the patient vs a collateral. 4 min · Updated Jun 2026](/guides/how-to-document-interpreter-or-collateral-participation) 1. [### Build a custom intake template in 15 minutes Build a Nextvisit intake template: editor path, variable tokens, required sections, and when to split into a second template. 4 min · Updated Apr 2026](/guides/build-custom-intake-template) 1. [### Privacy and 42 CFR Part 2, what changes in your charting What 42 CFR Part 2 requires for SUD records: who it covers, consent, segregation, disclosure logs, and how it changes the workspace. 5 min · Updated Mar 2026](/guides/privacy-42-cfr-part-2) 1. [### What a psychiatry AI scribe has to capture What a psychiatry AI scribe has to capture: DSM-5 templates, live notes, HIPAA handling, EHR export, and audit-ready outcomes. 2 min read · Updated Dec 2025](/guides/top-features-to-look-for-in-an-ai-scribe-for-psychiatry) 1. [### What matters in a psychiatry AI scribe Evaluate psychiatry AI scribes for specialty templates, risk language, and session-to-session context. 3 min read · Updated Oct 2025](/guides/choosing-the-best-ai-scribe-for-psychiatry-practices) Want a guide we don't have yet? ## Tell us what you'd want to read. If a workflow is missing, send a note. We write guides from onboarding questions. [Email the team](mailto:support@nextvisit.ai) [Book a 15-min demo](mailto:hello@nextvisit.ai) Live in 2 weeks or less BAA signed by default