Skip to main content
Headway

Compliance and documentation

How to write psychiatry progress notes (with examples)

Write psychiatry progress notes faster with templates and examples designed to save time while meeting clinical and insurance requirements.

November 14, 2025 • Updated on April 3, 2026

By Dr. Juli Fraga, Psy.D

8 min read

By Dr. Juli Fraga, Psy.D

Progress notes are an important part of your work as a prescriber. They provide a historical account of your patient’s mental health history and clinical care. These notes also allow you to keep track of treatment goals and prescribed medications. 

With time pressure and high caseloads, many prescribers strive to strike a balance between writing brief, yet comprehensive notes. There’s not one standard style of note-taking. Methods vary, and it’s important to choose a style that works best for you. This can feel overwhelming. But it doesn’t have to be. 

Read on to learn everything you need to know about how to write progress notes that meet clinical and insurance requirements.

Key insights

1

To meet insurance standards, psychiatry progress notes must show that you provided a particular patient with the services you billed for, on the specific date you billed for them.

2

Using a template can help you write thorough yet succinct progress notes — and finish them within 72 hours of each session, as required by many insurers.

3

Headway supports psychiatrists by providing free documentation templates and an AI assistant that turns session summaries into compliant notes in a flash.

The importance of documentation in billing insurance for psychiatry

If you bill insurance, payers may ask to review your notes to ensure compliance. Notes confirm that you provided services on the date billed to insurance. 

Documentation also helps you keep track of your patient’s treatment plan, goals, and progress. This information is important in case your notes are audited. Progress notes are also helpful if you need to speak with an insurance representative about denied claims or billing issues.

Practice in-network with confidence

Simplify insurance and save time on your entire workflow — from compliance and billing to credentialing and admin.

Talk to a practice consultant

The importance of documentation in billing insurance for psychiatry sessions

It can feel confusing to balance clinical insight with insurance compliance. Prescribers often want to protect their patients' confidentiality while also including all necessary information for ethical and legal purposes. 

If you’re wondering what type of information to include in your note, having a checklist can provide some guidance. Here’s a documentation checklist of what all prescribers, including psychiatrists and psychiatric nurse practitioners, need to document in each note. 

  • Ensure the CPT & ICD-10 codes listed in the documentation match those billed.
  • The date of service (DOS) in the note should match the DOS billed.
  • Include the patient’s full name and DOB on every page. 
  • Make sure the chief complaint or reason for encounter is clearly documented (e.g., “follow-up” alone is insufficient; specify the symptoms or problems being followed up on). 
  • Provider Signature: Include “Electronically Signed by: (Name/Credentials/Date signed)” and ensure the note is signed within 72 hours of the date of service.
  • Documentation should be unique to the patient and date of service with person-centered details (e.g., behavior descriptions, quotes). Avoid cloning or copy/paste. 
  • New patients: Include history for best practice (not required but improves quality of care), such as: prior mental health treatment, prior medical treatment/current conditions, psychosocial information
  • Clearly document the patient’s mental health status exam.
  • Clearly document any known allergies, or report “no known allergies” if there are none. 

Documentation guidelines for insurance reimbursement

  • Separate add-on psychotherapy documentation from evaluation and management (E/M) sections (best practice to place it at the bottom of the note, before your signature.
  • If you provided psychotherapy, this add-on time should be separate from the E/M time, documenting start and stop times. For example:

Appointment duration 2:30 pm -3:20 pm

Psychotherapy time: 2:45 pm-3:20 pm

Documentation guidelines for medication management

  • After each session, document the name, dosage, and frequency for each medication prescribed. Be sure to include medications managed by another provider and clearly state that you are not the prescriber for these medications. 
  • If the patient refuses the recommended medications, clearly state your recommendation, the reason for it, and the patient’s reason for refusal. 
  • For all prescribed medications, document risks and the importance of adherence.
  • If a controlled substance was prescribed, document that the PDMP was checked as per state mandate. 

A template to use for psychiatry progress notes

Having a template can help you decide which type of progress note you’d like to write. Think of it like a roadmap that guides the note-taking process. 

At Headway, we’ve built AI-assisted notes into our EHR for prescribers. AI session notes don’t replace your knowledge or expertise. They streamline the documentation process, so you can work more efficiently while maintaining comprehensive notes. After your session, you can open Headway’s note tool and write a brief summary of your session. From the summary, you can generate a compliant note with AI assistance. Once the note is generated, you can edit and add to the note as you see fit. 

Here's a suggested template offered to Headway providers to write their progress notes. It makes documentation easier by covering all of the crucial clinical information you need to proceed with treatment.

Patient information

Patient name: 

DOB: 

Address: 

Age: 

Sex: 

Relationship status: 

Occupation:

Contact information: 

Emergency contact: 

Insurance information: 

Date of evaluation: 

Evaluator: 


General

Chief complaint:

Interval events:


Alcohol and substance use

Select which of the following apply and include commentary on both current and past use:


Alcohol

[ ] Endorses [ ] Denies [ ] Not selected

Tobacco/nicotine

[ ] Endorses [ ] Denies [ ] Not selected

Cannabis

[ ] Endorses [ ] Denies [ ] Not selected

Hallucinogens

[ ] Endorses [ ] Denies [ ] Not selected

Opioids

[ ] Endorses [ ] Denies [ ] Not selected

Methamphetamine

[ ] Endorses [ ] Denies [ ] Not selected

Other

[ ] Endorses [ ] Denies [ ] Not selected


Other providers

Are there other relevant providers with whom the patient is collaborating?

[ ] Primary care physician

[ ] Other mental health providers

[ ] Other medical providers

Please provide details:


Medical history

Allergies:

Active medications at start of session:

Medical conditions:

Vital signs:

Relevant test results:

Results of C-SSRS:


Risk assessment

Suicidal ideation

[ ] Denies suicidal ideation

[ ] Wish to be dead with thoughts of suicide

[ ] Ideation without intent or plan

[ ] Intent

[ ] Plan

[ ] Access to means

[ ] Other


Self harm

[ ] Denies urge to self-farm

[ ] Urges without plan or intent

[ ] Intent

[ ] Recent self-harm behaviors

[ ] Other


Homicidal ideation

[ ] Denies homicidal ideation

[ ] Ideation without intent or plan

[ ] Identified victim

[ ] Intent

[ ] Plan

[ ] Access to means

[ ] Other


Violent/destructive behavior

[ ] Denies urges for violent/destructive behavior

[ ] Urges without plan or intent

[ ] Identified victim

[ ] Intent

[ ] Plan

[ ] Recent violent or destructive acts

[ ] Other


Additional relevant information:


History of harm

History of self harm

[ ] Endorses [ ] Denies [ ] Not selected

History of suicidal ideation

[ ] Endorses [ ] Denies [ ] Not selected

History of suicide attempts

[ ] Endorses [ ] Denies [ ] Not selected

History of harm to others

[ ] Endorses [ ] Denies [ ] Not selected

History of violent/destructive behavior

[ ] Endorses [ ] Denies [ ] Not selected

Other

[ ] Endorses [ ] Denies [ ] Not selected


Protective and risk factors

Static risk factors/static liabilities:

Modifiable risk factors/modifiable liabilities:

Protective factors/strengths:

What actions have been taken to minimize risk, if any?


What is the patient’s current overall, acute risk of harm to themselves or others?

[ ] Low [ ] Moderate [ ] High


Safety plan:


Mental status exam

Attention:

Orientation:

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought process:

Thought content:

Memory:

Judgement:

Insight:


Assessment and plan

Diagnostic formulation:

Justification for medical necessity:

Plan:

Example psychiatry progress note

Patient Information

Patient name: John Doe

DOB: 09/02/1982

Address: 1000 Main Street, Chicago, IL

Age: 43

Sex: Male

Relationship status: Married

Occupation: High school history teacher

Contact information: (555) 555-9213 | [email protected]

Emergency contact: Jane Doe (spouse) – (555) 555-2397

Insurance information: Aetna PPO

Date of evaluation: 11/06/2025

Evaluator: Allison Therapist, PMHNP-BC


General

Chief complaint:

“I’ve been feeling better overall, but my sleep still isn’t great.”

Interval events:

Patient seen today for a 4-week medication management follow-up. Reports partial improvement in mood and energy since starting sertraline 50 mg daily. States he feels “more even” and less irritable. However, he continues to experience difficulty maintaining sleep and occasional early-morning awakenings. Denies anhedonia, hopelessness, or suicidal ideation. Notes mild sexual side effects from sertraline but prefers to continue given the benefit.

He reports reduced alcohol consumption since last visit (from nightly 3–4 drinks to 1–2 on weekends). No withdrawal symptoms or cravings. Plans to resume exercising and spending more time outdoors.


Alcohol and substance use

Alcohol

☑ Endorses — currently drinks socially (1–2 drinks on weekends); previously reported heavier use (3–4 nightly drinks) before initiating treatment. Reports continued progress toward moderation

Tobacco/nicotine

☐ Endorses

☑ Denies — quit smoking 5 years ago

Cannabis

☐ Endorses

☑ Denies — no current or past use

Hallucinogens

☐ Endorses

☑ Denies

Opioids

☐ Endorses

☑ Denies — no history of use or misuse

Methamphetamine

☐ Endorses

☑ Denies

Other

☐ Endorses

☑ Denies


Other providers

Are there other relevant providers with whom the patient is collaborating?

☑ Primary care physician — Dr. Henry Wu

☑ Other mental health providers — individual therapist (CBT)

☐ Other medical providers

Please provide details:

Therapist: Carla Nguyen, LCSW, weekly sessions. PCP manages hypertension and coordinates lab monitoring.


Medical history

Allergies: No known drug allergies.

Active medications at start of session:

  • Sertraline 50 mg PO daily
  • Lisinopril 10 mg PO daily

Medical conditions:

Hypertension, well-controlled; mild obstructive sleep apnea (using CPAP).

Vital signs: BP 122/80 mmHg, HR 72 bpm, RR 16/min, Temp 98.1°F, BMI 26.2

Relevant test results: Last comprehensive metabolic panel (October 2025): WNL.

Results of C-SSRS: Denies suicidal ideation or behavior.


Risk assessment

Suicidal ideation

☑ Denies suicidal ideation

Self harm

☑ Denies urge to self-harm

Homicidal ideation

☑ Denies homicidal ideation

Violent/destructive behavior

☑ Denies urges for violent/destructive behavior

Additional relevant information:

No access to firearms or weapons. Patient demonstrates good judgment and insight into risk behaviors.


History of harm

History of self harm

☐ Endorses

☑ Denies

History of suicidal ideation

☐ Endorses

☑ Denies

History of suicide attempts

☐ Endorses

☑ Denies

History of harm to others

☐ Endorses

☑ Denies

History of violent/destructive behavior

☐ Endorses

☑ Denies

Other

☐ Endorses

☑ Denies


Protective and risk factors

Static risk factors/static liabilities: Middle-aged male; past heavy alcohol use.

Modifiable risk factors/modifiable liabilities: Sleep disruption, residual depressive symptoms, occupational stress.

Protective factors/strengths: Strong family support, ongoing therapy engagement, insight into illness, active lifestyle goals, reduced alcohol intake.

What actions have been taken to minimize risk, if any?

Continued SSRI therapy, ongoing CBT, alcohol reduction plan, reinforcement of coping skills and sleep hygiene.

What is the patient’s current overall, acute risk of harm to themselves or others?

☑ Low

Safety plan: Patient instructed to contact emergency services or on-call provider for any escalation in suicidal thoughts. Crisis resources reviewed.


Mental status exam

Attention: Focused and sustained throughout session.

Orientation: Fully oriented ×4.

Appearance: Casually dressed, well-groomed.

Behavior: Calm, cooperative, good eye contact.

Speech: Normal rate, rhythm, and tone.

Mood: “A bit tired, but better.”

Affect: Mildly constricted but appropriate and congruent.

Thought process: Logical, coherent, goal-directed.

Thought content: No delusions or obsessions. Denies suicidal or homicidal thoughts.

Memory: Grossly intact.

Judgment: Good.

Insight: Good.


Assessment and plan

Diagnostic formulation:

43-year-old male with Major Depressive Disorder, recurrent, mild, and Alcohol Use Disorder, mild, currently in early remission. Reports ongoing improvement in mood and functioning, continued sleep disturbance, and residual anxiety.

Justification for medical necessity:

Ongoing management of depressive and substance-related symptoms requiring medication monitoring, psychotherapy coordination, and functional assessment.

Plan:

  • Continue sertraline 50 mg daily.
  • Reassess sleep at next visit; consider dose adjustment or adjunctive medication if persistent.
  • Continue CBT with current therapist.
  • Encourage consistent CPAP use and resumption of exercise routine.
  • Reinforce moderation with alcohol; monitor for relapse risk.
  • Follow up in 6 weeks or sooner if symptoms worsen.

Tips for writing effective and compliant progress notes for psychiatry sessions

  • Be clear: Using a template or following a format can help you write clear and concise progress notes. Templates also ensure that you include all the necessary information for insurance documentation and reimbursement. 
  • Be comprehensive: Include all necessary information (as outlined in the template above) and use concise language. 
  • Only include clinically relevant information: To protect your patient’s confidentiality, only include information that is clinically relevant to their treatment goals, interventions, and treatment plan. 
  • Be prompt: Complete your note as soon as possible. Many insurance payers require prescribers to complete notes within 72 hours of the appointment. Prompt documentation ensures that insurance payers will reimburse for services and can help avoid delays.

Explore more psychiatry support resources from Headway

Looking to learn more about documentation, billing insurance, practice management, and other need-to-know topics for prescribers? Consult Headway’s expansive library of resources for providers.

Psychiatric practice support resources:

How Headway supports prescribers:

Elevate your practice with Headway

Writing progress notes can feel overwhelming and time-consuming. Headway is here to help your psychiatry practice. Our platform streamlines documentation and supports compliance with insurance requirements — allowing psychiatrists and prescribers to spend more time on direct patient care.

Talk to a practice consultant

This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

Compliance and documentation

How to write progress notes

Progress notes are the core piece of documentation a provider should write after each client session, but it’s more than just a record of what happened.