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Clinical notePsychiatry

Psychiatric Evaluation

Comprehensive initial psychiatric evaluation with psychiatric, substance, and social history, mental status exam, structured risk assessment, formulation, and treatment plan.

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What’s in this template

13 sections, in the order they appear in the finished document.

  1. 1Identifying Information & Reason for ReferralParagraph
  2. 2Chief ComplaintParagraph
  3. 3History of Present IllnessParagraph
  4. 4Past Psychiatric HistoryBullets
  5. 5Substance Use HistoryBullets
  6. 6Medical HistoryBullets
  7. 7Medications & AllergiesBullets
  8. 8Family Psychiatric HistoryBullets
  9. 9Social & Developmental HistoryBullets
  10. 10Mental Status ExaminationBullets
  11. 11Safety & Risk AssessmentBullets
  12. 12Diagnostic Impression & FormulationAuto
  13. 13Treatment PlanBullets

“Auto” sections use whichever format reads most clearly for what was discussed: prose or a list.

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