Psychiatry Progress Note Templates (2026 Edition)

Mental health care is constantly changing, with its best documentation practices. A properly formatted psychiatry progress note is not merely a form to psychiatrists, psychiatric nurse practitioners, and other mental health clinicians, but a much-needed instrument in patient care and communication with the rest of the treatment team, as well as billing.

The need to be efficient, specific, and comply with the new regulatory standards has never been greater. In this blog, you’ll know the best and the latest progress note templates in psychiatry, so that your work is exhaustive and time-saving.

What are Psychiatry Progress Notes?

The psychiatry progress notes are the chronological, written documents of the mental health process of a patient, which document all the encounters, interventions, and changes of status. They are the main communication point for all the providers of the patient.

• A good progress note is a concise but detailed summary of:
• Subjective experience of the patient since the last visit.
• The objective observations and mental status examination (MSE) of a clinician.
• The evaluation of the patient in terms of current condition, diagnosis, and the effectiveness of the treatment plan.
• Detailed work out of the further steps, drug changes, laboratory tests, and treatment objectives.

The notes are necessary to prove the necessity of medicine, justification of the level of provided care, and, finally, continuity and quality of care.

Types of Psychiatry Progress Notes (SOAP, DAP, BIRP, EMR-based)

1. SOAP Notes

The most commonly used format is arguably the SOAP notes format, which is the psychiatry format. The flow is quite simple and logical, and it is a gold standard.

S – Subjective: The chief complaint, symptoms, and subjective experience of the patient. Provide quotes where necessary.

O – Objective: Observations made by the clinician objectively, such as Mental States Exam (MSE), vital signs, rating scales results, or laboratory results.

A – Assessment: The summary of the current state, differential diagnosis, and analysis of efficacy of the treatment made by the clinician.

P – Plan: Future-focused specific interventions, such as a change in medication, referrals, scheduling of follow-ups, and therapeutic interventions.

2. DAP Notes

DAP notes are simpler in nature and are likely to be preferred by the therapist, though they may also be used during a psychiatric visit.

D – Data: Integrates Subjective and Objective data of SOAP.

A – Assessment: The same as the SOAP Assessment.

P – Plan: Same as the SOAP Plan.

3. BIRP Notes

BIRP notes tend to apply to an area that concentrates on behavioral interventions.

B – Behavior: Objective information concerning the behavior and the impact of the patient.

I – Interventions: What the clinician utilizes during the session, specifically CBT techniques, motivational interviewing, and medication education.

R – Response: This is how the patient reacts to the interventions.

P – Plan: The next steps and treatment objectives.

4. EMR-Based Templates

EMRs such as Epic, Cerner, and specialty mental health services tend to utilize hybrid, tailorable templates. The systems often use pre-population of fields and dropdown menus so that all the billing and compliance needs are fulfilled, thus making them very efficient for the busy clinician.

Best Practices for Psychiatric Documentation 

Mastering how to write psychiatry progress notes is not a simple task of typing in a template. It is very important to follow the best practices in mental health documentation:

1. Be Specific, Not Vague

Rather than saying that the patient is feeling better, describe the situation, i.e., the patient reports that there is a 50% decrease in intrusive thoughts and that he/she sleeps 7 hours a night.

2. Document Medical Necessity 

It is important to explain the necessity of every intervention (change of medication, duration of the session, etc.) in the Assessment section. Be able to directly tie an intervention to a symptom that is leading to functional impairment.

3. Add Safety Documentation

It is important to always write down the examination of suicidal ideation (SI), homicidal ideation (HI), and self-harm, even when denied. This is an inflexible legal and clinical requirement.

4. Apply Quotation Marks

When generalizing the feelings and complaints of the patient, direct quotes are applied in the Subjective part to retain objectivity and accuracy.

5. Review the Treatment Plan

It should be obvious in the Assessment and Plan whether the same treatment plan is not appropriate anymore and should be changed or not. They are great examples of progress notes in psychiatry.

Psychiatry Progress Note Samples

S – Subjective: 

The patient comes to the 2-week follow-up. Reported as being a little less tired, but not that motivated to go out. Denies development of new depressive symptoms or high levels of anxiety. Denies SI/HI/AH. The patient is adherent to her dosage of Sertraline 50 mg/day. The main stressor is still a conflict with her landlord.

O – Objective: 

Appearance: Clean, cooperative. Affect: Limited, consistent with mood. Mood: “Okay.” Thinking Process: Linear, goal-oriented. Thought Process: No delusion or paranoid thought. MSE: WNL (Within normal limits) except mild psychomotor retardation.

A – Assessment: 

GAD (F41.1) and MDD (F33.0). The patient partially responds to the present regimen, as energy improves, but anhedonia persists. As of now, the Sertraline dose is tolerated and has no side effects. The risk of self-harm remains low.

P – Plan: 

1. Medication: Repeat Sertraline 75mg/day. Justification/ rationale: Titrate till therapeutic dose achieved, partial response, and well tolerated. 

2. Therapy: Keep doing individual CBT every week. 

3. Safety: Reiterate crisis plan. 

4. F/U Follow-up in 4 weeks to check medication and re-evaluate symptoms.

Related: The Role of Cloud EHRs in Measurement-Based Psychiatry

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