A psychiatric SOAP note has to carry an MSE, a risk assessment, and a polypharmacy plan with monitoring. Generic templates fold that into one assessment paragraph. Auditors notice. So does the next clinician on the chart.
Default for psychiatrists, NPs, and PAs on med-management visits. Affect and thought process have their own labels. Suicidality and homicidality are structured fields. Medication changes track reason, dose, and follow-up parameter.
Patient: [patient_name] DOB: [dob] Age: [age]
Date: [encounter_date] Provider: [provider_name] Duration: [duration]
Subjective
- Chief complaint (in patient's own words):
- History of present illness (interval since last visit, symptom course, sleep, appetite, energy, concentration, anhedonia, anxiety, panic, mood reactivity):
- Medication adherence and side effects:
- Substance use update:
- Stressors, supports, recent life events:
- Patient goals for this visit:
Objective
- Vitals (if obtained):
- Mental Status Exam
- Appearance and behavior:
- Speech:
- Mood (patient-reported):
- Affect (clinician-observed):
- Thought process:
- Thought content:
- Perceptions:
- Cognition and insight:
- Judgment:
- Risk assessment
- Suicidal ideation (passive/active, plan, intent, means, prior attempts):
- Homicidal ideation:
- Risk factors:
- Protective factors:
- Clinical risk impression:
Assessment
- Primary diagnosis (with ICD-10):
- Secondary or comorbid diagnoses:
- Diagnostic clarification (rule-outs, deferred diagnoses):
- Clinical formulation (interval response to treatment, residual symptoms):
Plan
- Medication continued:
- Medication changes (drug, dose, reason, monitoring parameter):
- Therapy referral or coordination:
- Labs ordered (lithium level, lipid panel, TSH, CBC, CMP, drug screen, etc.):
- Safety planning if relevant:
- Patient education provided:
- Follow-up interval:AriaMD routes as it hears the visit. Patient-reported mood lands in mood. Observed affect lands in affect. Suicidal ideation lands in the risk field with the patient’s framing, not paraphrased into the HPI. Medication changes keep reason and monitoring parameter. You sign the note and own the diagnosis.