Psychiatry SOAP Note Template

The Psychiatry SOAP Note template keeps what the patient reported separate from what you observed, which is exactly the separation reviewers look for in a medication management visit. Across two pages it carries interval history and adherence, a full mental status exam, vitals and metabolic monitoring including AIMS where an antipsychotic is involved, rating scales such as PHQ-9 and GAD-7, and an assessment that ties diagnosis to functional impairment, progress, and risk.

What makes it different from a generic layout is the coding and compliance guidance built into the page. It carries the encounter fields payers look for, including place of service and telehealth modifiers, and it spells out the prescriber coding path: an evaluation and management code with a psychotherapy add-on where therapy also occurred, and a warning that a standalone psychotherapy code billed alongside an E/M denies as a duplicate service. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.