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How to Write a Psychiatric Intake Note: Comprehensive Guidelines
Psychiatric intake notes (also known as initial evaluation notes) play a crucial role in mental health documentation. They record the patient's first psychiatric evaluation, form the basis of ongoing care, and facilitate clear communication between healthcare providers. Crafting an accurate, thorough, and compliant psychiatric intake note is essential for legal, clinical, and therapeutic reasons.
In This Article, You Will Learn:
The key components of a well-written psychiatric intake note
Best practices for clear, professional documentation
A structured template you can adapt for your practice
Important Disclaimer: This article is for informational purposes only and not a substitute for clinical or legal advice. Always follow local practice guidelines, HIPAA (or other relevant privacy laws), and consult with your supervisor or institution if you have specific documentation questions.
Why Proper Documentation Matters for Psychiatric Intake Assessments
Proper documentation in psychiatric intakes benefits both clinicians and patients in several ways:
Ensures continuity of care for the patient
Provides clear communication among clinical team members
Protects against medico-legal risks
Facilitates accurate diagnosis and individualized treatment planning
Promotes patient safety through explicit documentation of risk assessment
Key Components of a Psychiatric Intake Note
A psychiatric intake note generally includes the following components, organized logically to guide assessment and treatment:
Identifying Information & Chief Complaint (CC)
History of Present Illness (HPI)
Past Psychiatric History
Substance Use History
Medical History
Medications and Allergies
Family History
Social & Developmental History
Mental Status Examination (MSE)
Assessment (Diagnostic Impression)
Treatment Plan
Let's detail each one.
1. Identifying Information & Chief Complaint
Begin the note by clearly documenting basic patient information and the patient's exact reason for seeking care, ideally in their own words.
Example:
Name/Age/Gender: "Maria L., 28-year-old female"
Chief Complaint: "I feel so depressed; I don't want to get out of bed."
2. History of Present Illness (HPI)
Describe in detail the presenting problem:
Symptom onset and progression
Stressors/factors contributing to aggravation or alleviation
Daily functioning impact (work, relationships)
Treatments or coping methods attempted
Example: "Maria reports depression gradually worsening over the last three months following job loss. Symptoms include persistent sadness, fatigue, anhedonia, and disrupted sleep. Denies suicidal ideation. No prior psychiatric treatment attempted. Symptoms significantly impair ability to seek new employment and maintain social relationships."
3. Past Psychiatric History
Include previous diagnoses, treatments, hospitalizations, medicines, suicide attempts, trauma, or abuse history.
4. Substance Use History
Document current and past use of substances including tobacco, alcohol, illicit drugs, prescription misuse, frequency, duration, and related treatment history.
5. Medical History
Briefly describe pertinent medical conditions, especially those that might impact psychiatric diagnosis (e.g., thyroid disorders), and relevant medications or allergies.
6. Medications and Allergies
Clearly list current medications with dosages and known allergies or adverse reactions.
7. Family History
Include family psychiatric and relevant medical histories (e.g., "Father with Bipolar Disorder," "Maternal grandmother died by suicide"), providing insight into genetic or environmental risks.
8. Social & Developmental History
Summarize social factors (relationships, living situation, employment, education) and developmental history (especially for adolescents and children), including any significant stressors or supports.
9. Mental Status Examination (MSE)
An objective summary of the patient’s presentation during evaluation, documenting:
Appearance and Behavior: grooming, hygiene, notable behaviors
Speech: quantity, rate, tone, abnormalities
Mood (patient-reported) and Affect (your observation): congruence, range, appropriateness
Thought Process: organized, tangential, etc.
Thought Content: presence or absence of delusions, suicidal/homicidal ideation
Perception: hallucinations or other disturbances
Cognition: orientation, memory, abstraction, attention/concentration
Insight and Judgment: patient’s understanding of illness and decision-making capacity
Example MSE Excerpt: "Patient appears fatigued, casually but appropriately dressed, makes intermittent eye contact. Speech slow, soft-spoken. Mood 'depressed,' affect congruent, restricted. Thought process coherent but slow. Denies suicidal/homicidal ideation or perceptual disturbances. Cognition intact, oriented ×4. Fair insight, judgment intact."
10. Assessment and Diagnostic Impression
Clearly state your clinical interpretation and include DSM-5 diagnoses or differential diagnoses, ranked by priority. Include risk assessment explicitly.
Example: "Maria L. is a 28-year-old female presenting with a three-month history of depressive symptoms following unemployment. Diagnoses:
Major Depressive Disorder, single episode, moderate severity (DSM-5 296.22).
Adjustment Disorder with Mixed Anxiety and Depressed Mood (to rule out). Low acute suicide risk but will monitor closely."
11. Treatment Plan
Clearly outline next steps related to identified problems, such as:
Recommended psychiatric medications or therapy referrals (include informed consent discussion)
Additional medical or psychological evaluations suggested
Safety planning considerations
Patient education provided
Plans for follow-up appointments or referrals
Example Treatment Plan:
Medication: Initiate sertraline 25mg daily for depression/anxiety after discussion of risks and benefits; obtain informed consent.
Psychotherapy: Referred to outpatient Cognitive Behavioral Therapy (CBT), provided therapist list.
Safety: No current suicidal ideation; provided crisis hotline and emergency department instructions.
Follow-up: Return clinic visit in two weeks to evaluate medication initiation, sooner if needed.
Documentation Best Practices for Psychiatric Intake Notes
Use professional, clear, concise, objective language
Document safety or risk concerns explicitly
Employ clear headings and bullet points to enhance readability
Avoid unnecessary detail unrelated to clinical assessment or treatment planning
Respect patient confidentiality and adhere to HIPAA or other local regulations
Complete documentation promptly after the intake to ensure accuracy and thoroughness
Structured Psychiatric Intake Note Template
Feel free to adapt this structured template in your clinical practice:
Identifying Information:
Name/Age/Gender:
Date/Time/Location:
Chief Complaint:
Patient’s stated primary issue:
History of Present Illness (HPI):
Onset, progression, severity:
Impact on functioning:
Coping attempts or previous interventions:
Past Psychiatric History:
Previous diagnoses and treatments:
Hospitalizations, suicide attempts, trauma history:
Substance Use History:
Current/past substance use details:
Medical History:
Pertinent medical conditions and surgeries:
Medications/Allergies:
Current medications; allergies:
Family History:
Psychiatric and relevant medical history:
Social/Developmental History:
Social supports, stressors, significant life events:
Mental Status Examination (MSE):
- Appearance/Behavior:
- Speech:
- Mood/Affect:
- Thought Process/Content:
- Perception:
- Cognition:
- Insight/Judgment:
Assessment/Diagnoses:
- Diagnostic impression with DSM-5 criteria:
Treatment Plan:
- Recommended interventions (therapy, medication):
- Safety considerations, instructions provided:
- Follow-up plan/date and additional referrals:
Conclusion
By clearly structuring your psychiatric intake notes and adhering to best practices, you ensure thorough communication, accurate diagnoses, and improved continuity of care for your patients. Following these guidelines will help you produce documentation that reflects both professional standards and compassionate patient-centered care.
Shanice
Author, Nudge AI
