Headings
Chief complaint · Interval history · Current medications · Adherence and side effects · Mental status exam · Risk assessment · Assessment · Medication changes · Plan
When to use it
Built for psychiatrists, psychiatric nurse practitioners and PAs doing short follow-up visits focused on medication. It records the current regimen, adherence, side effects and the exact dose changes made that day. Therapy notes rarely need these sections, so use this one only for prescribing visits.
Example
Fictional example
Chief complaint
G.H., 58, follow-up for bipolar II disorder. “Steadier, but I’m not sleeping well.”
Interval history
No hypomanic episodes since last visit. Low mood two or three days a week. Falls asleep after 1 a.m. most nights.
Current medications
Lamotrigine 150 mg daily. Levothyroxine 75 mcg daily.
Adherence and side effects
Uses a pill organizer, missed one dose in eight weeks. No rash. Mild morning headache.
Risk assessment
Denies suicidal ideation. Lives with her husband. No firearms in the home.
Medication changes
Increase lamotrigine to 200 mg daily. Reviewed rash warning signs again.
Plan
Sleep hygiene handout. Follow up in six weeks. Call sooner for rash or mood elevation.