Practical Provider Group
Clinical Templates Pack — Free Sample
Sample: Psychiatric Follow-Up Note Template
A preview of the C3 Documentation System. The full pack includes 15+ templates, screening tools, and billing code references.
Psychiatric Follow-Up Appointment Note
C3 Documentation System · Practical Provider Group, LLC · Adapt for your EHR
Administrative
Date of Service
[DATE]
CPT Code
[99214 / 99213 / 90833+99214]
Interval History
Patient is a [age]-year-old [gender] presenting for [routine follow-up / medication management / crisis follow-up] with diagnoses of [diagnosis list]. Since last visit on [date], patient reports [summary of interval — symptom changes, medication response, significant events, functional status].
Medication Response
Current medications: [list]. Patient reports [response to each medication — efficacy, tolerability, adherence]. PHQ-9 score today: [score] (prior: [score]). GAD-7 score today: [score] (prior: [score]).
Mental Status Exam
Appearance / Behavior
[Well-groomed / disheveled] [cooperative / guarded / hostile] [good eye contact / poor eye contact]
Speech
[Normal rate / pressured / slowed] [normal volume] [clear / tangential]
Mood (patient-reported)
"[Patient's own words]"
Affect
[Full / constricted / flat / labile] [mood-congruent / incongruent]
Thought Process
[Logical / organized / circumstantial / tangential / disorganized]
Thought Content
[No delusions / [describe if present]] [No hallucinations / [describe if present]]
Cognition
[Alert and oriented x3] [memory intact] [concentration [intact / impaired]]
Insight / Judgment
[Good / fair / poor] insight. [Good / fair / poor] judgment.
Safety Assessment
Patient [denies / reports] suicidal ideation. [If denies: No plan, intent, or means reported.] [If present: describe fully — passive vs. active, plan, means, intent, protective factors.] Patient [denies / reports] homicidal ideation. No concern for imminent harm to self or others at this time. [Or: Safety plan reviewed / updated / crisis resources provided.]
Assessment and Diagnoses
[Primary diagnosis] [DSM-5-TR code] — [stable / improved / worsening / unchanged]
[Additional diagnoses as applicable]
[Additional diagnoses as applicable]
Plan
1. Medications: [Continue / adjust / discontinue / add] [medication, dose, frequency]. [Clinical rationale for any changes.]
2. Labs: [None indicated / obtain [specific labs] by [date].]
3. Therapy: [Patient [is / is not] engaged in therapy with [provider name/type]. [Referral placed / coordination discussed].]
4. Patient education: [Topics discussed — [list].]
5. Follow-up: Return to clinic in [interval] for [reason].
6. [Any additional plan elements.]
2. Labs: [None indicated / obtain [specific labs] by [date].]
3. Therapy: [Patient [is / is not] engaged in therapy with [provider name/type]. [Referral placed / coordination discussed].]
4. Patient education: [Topics discussed — [list].]
5. Follow-up: Return to clinic in [interval] for [reason].
6. [Any additional plan elements.]
Time and Coordination
Total time: [X] minutes. [If billing time-based: Time spent: [X] minutes in [direct patient care / coordination of care / counseling]. [If 99213/99214: Medical decision-making level: [low / moderate / high complexity].]
Get the full Clinical Templates Pack
- New patient psychiatric intake template
- This follow-up note template (formatted version)
- SOAP progress note template
- Treatment plan framework
- CPT billing code reference guide
- PHQ-9, GAD-7, C-SSRS, PCL-5, MDQ, AUDIT screening tools
- Diagnosis outlines for 10 conditions