Sixty minutes of conversation has to become a chart another clinician, a payer, and a future you can act on. A four-paragraph summary is a recap, not an intake.
Ships for psychiatrists, psychiatric NPs, and PAs. Covers chief complaint and HPI, psychiatric history including hospitalizations and prior med trials, family and social history, substance use, MSE, formal risk, differential with reasoning, and a treatment plan with monitoring. Sized for 45 to 60 minutes and CPT 90792.
Patient: [patient_name] DOB: [dob] Age: [age] Gender: [gender]
Date: [encounter_date] Provider: [provider_name] Duration: [duration]
Referral source: [referral_source] Pronouns: [pronouns]
Chief complaint (in patient's own words):
History of present illness
- Onset, course, severity, frequency:
- Triggers and precipitants:
- Modifying factors:
- Current symptoms (depression, anxiety, panic, mania, psychosis, sleep, appetite, concentration, anhedonia):
- Functional impact (work, school, relationships, self-care):
Past psychiatric history
- Prior diagnoses:
- Hospitalizations (date, facility, reason, length of stay):
- Suicide attempts and self-harm history:
- Prior medication trials (drug, dose, duration, response, reason discontinued):
- Prior therapy and modality:
- ECT, TMS, ketamine, Spravato history:
Substance use history
- Current use (alcohol, cannabis, stimulants, opioids, benzodiazepines, tobacco, other):
- Pattern, quantity, last use:
- Past treatment for SUD:
Past medical history and surgeries:
Allergies and current medications (psychiatric and non-psychiatric):
Family psychiatric and medical history:
Social and developmental history
- Childhood and developmental milestones:
- Trauma history (screened with patient consent):
- Education and occupation:
- Relationships and supports:
- Legal history:
- Military history:
Mental Status Exam
- Appearance and behavior:
- Speech:
- Mood and affect:
- Thought process and content:
- Perceptions:
- Cognition, insight, judgment:
Risk assessment
- Suicidal ideation, plan, intent, means:
- Homicidal ideation:
- Self-harm urges or behavior:
- Risk factors:
- Protective factors:
- Clinical risk impression:
Diagnostic impression and differential (with ICD-10):
Treatment plan
- Medication recommendation (drug, starting dose, titration plan, monitoring):
- Therapy recommendation and referral:
- Labs and baseline studies ordered:
- Safety planning:
- Coordination with PCP or other providers:
- Patient education and informed consent documented:
- Follow-up interval:AriaMD routes as it hears the intake. MSE lands in MSE. Risk lands in risk with the patient’s framing. A passing mention of a prior med trial keeps dose, duration, and reason discontinued. Direct quotes stay in the chief complaint when a paraphrase would lose meaning. You review, edit, and sign.