Mental Health Note: Structure and Sections
Psychiatric or mental health assessment and plan. Notermed's built-in Mental Health Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Mental Health Note contains
11 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Presenting Complaint
- The chief concern in the patient own words
- How long it has been going on, and the context
- 2
History of Present Illness
- Onset and course of the current symptoms
- Precipitating factors
- Impact on functioning
- Prior episodes and how they were treated
- 3
Psychiatric History
- Prior diagnoses
- Hospitalizations and outpatient treatment
- Previous medications and the response to them
- 4
Medical History
- Relevant medical conditions
- Current medications
- Allergies
- 5
Substance Use
- Alcohol, tobacco, cannabis, and other substances
- Type, frequency, and quantity
- 6
Social History
- Living situation and supports
- Relationships and employment
- Trauma history, if disclosed
- 7
Family History
- Family psychiatric history
- Relevant family medical history
- 8
Mental Status Examination
- Appearance, behaviour, and speech
- Mood in the patient own words, and affect
- Thought process, thought content, perceptual disturbances
- Cognition, insight, and judgment
- 9
Risk Assessment
- Suicidal ideation, intent, plan, and access to means
- Homicidal ideation
- Protective factors
- 10
Assessment
- DSM or ICD diagnosis, or working formulation, as stated
- 11
Plan
- Medications
- Psychotherapy
- Referrals
- Safety planning
- Crisis resources provided
- Follow-up
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Mental Health Note
What sections does the mental health note contain?
Eleven, from the Presenting Complaint and History of Present Illness through Psychiatric History, Medical History, Substance Use, Social History and Family History, to the Mental Status Examination, Risk Assessment, Assessment and Plan.
What does the risk assessment record?
Suicidal ideation with intent, plan and access to means, homicidal ideation, and protective factors, as they were discussed in the visit. It records what was asked and answered, and you edit it before you sign.
Does the note assign a diagnosis?
It records the DSM or ICD diagnosis, or the working formulation, as the clinician stated it. Nothing is diagnosed on your behalf.
Is a mental health note held any differently?
It is held the same way every note is, and that is the point. Patient data is stored and processed only on servers in the United States, encrypted in transit and at rest, and never used to train AI models, under a Business Associate Agreement signed with your clinic before any patient data is processed.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Mental Health Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.