Specialties
AI scribe for mental health clinics
A mental health note has sections no medical template carries. Notermed’s mental health format records the Mental Status Examination as appearance, behaviour and speech; mood in the patient’s own words, and affect; thought process, thought content and perceptual disturbances; cognition, insight and judgment. Its Risk Assessment section captures suicidal ideation, intent, plan and access to means, homicidal ideation, and protective factors. Substance use is recorded by type, frequency and quantity.
- Built-in formats1
- Sections across them11
- Structure reviewed
What a mental health note captures
Every line below is a field in the built-in mental health format. The draft fills a line only when the visit spoke to it; a section with nothing stated is left out rather than padded.
- 01
Presenting Complaint
- The chief concern in the patient own words
- How long it has been going on, and the context
- 02
History of Present Illness
- Onset and course of the current symptoms
- Precipitating factors
- Impact on functioning
- Prior episodes and how they were treated
- 03
Psychiatric History
- Prior diagnoses
- Hospitalizations and outpatient treatment
- Previous medications and the response to them
- 04
Medical History
- Relevant medical conditions
- Current medications
- Allergies
- 05
Substance Use
- Alcohol, tobacco, cannabis, and other substances
- Type, frequency, and quantity
- 06
Social History
- Living situation and supports
- Relationships and employment
- Trauma history, if disclosed
- 07
Family History
- Family psychiatric history
- Relevant family medical history
- 08
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
- 09
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
The format
One built-in format
Questions from mental health clinics
- How is the Mental Status Examination structured?
- Four groups: appearance, behaviour and speech; mood in the patient’s own words, and affect; thought process, thought content and perceptual disturbances; cognition, insight and judgment. Each is captured as you stated it during the visit.
- Does it have a dedicated risk section?
- Yes. Risk Assessment captures suicidal ideation, intent, plan and access to means, homicidal ideation, and protective factors. It is its own section so it is never buried in a paragraph.
- How is substance use recorded?
- Alcohol, tobacco, cannabis and other substances, by type, frequency and quantity, in a Substance Use section separate from the medical history.
- Is the format editable for my practice?
- Yes. You can add formats of your own, and save your own copy of any built-in one. The built-in one is a starting point that already has the psychiatric structure in place.
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.
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 it on one of your own mental health visits
Bring a consultation. We will record it, show you the draft in your format, and tell you plainly if Notermed is not a fit yet.