AI Scribe for Psychiatry
Transcribe Health drafts your intake, med-management, and therapy notes while you talk with the patient, so the mental status exam and the plan are on the page before the visit ends.
Photo: Priscilla Du Preez 🇨🇦 / Unsplash
Psychiatry documentation, from intake to med check
Psychiatry notes come in a few shapes, and they are not interchangeable. A new-patient intake runs long: history of present illness, past psychiatric and substance history, a full mental status exam, and a risk assessment, often 60 minutes of talking to write up. A med-management follow-up is shorter but dense in its own way, since it turns on symptom change, PHQ-9 or GAD-7 movement, side effects, and one or two dose decisions. A therapy session adds a psychotherapy note on top of the E/M work when you bill an add-on code.
The content is sensitive in a way most specialties never touch. You are writing about ideation, trauma, substance use, and family conflict, and the words matter for both care and later review. A vague risk note is a liability. A precise one, with the patient's own statements and your reasoning, protects everyone.
The real friction is the keyboard. Turning to type during a psychiatric visit costs you the rapport the visit runs on, and patients notice when you stop looking at them. So the note either gets half-written in the room or finished hours later from memory. Transcribe Health listens while you stay present, then drafts the note with the MSE, the scores, the medication changes, and the risk assessment in place. You read it, correct it, and sign. Nothing is filed without you.
Documentation Challenges in Psychiatry
- 1
Capturing a full mental status exam (appearance, mood and affect, thought process and content, insight, judgment) in the patient's own words without breaking eye contact to type it
- 2
Documenting risk assessment and safety planning: suicidal or homicidal ideation, means and intent, protective factors, and the reasoning behind the disposition, in language that holds up on later review
- 3
Tracking medication trials across long visits, prior agents that failed, current doses, side effects, and adherence, alongside PHQ-9 or GAD-7 scores over time
How Transcribe Health Helps Psychiatry
Structured Mental Status Exams
Pulls the MSE elements out of the conversation and lays them out in the format you use, so mood, affect, thought content, and cognition each land in their own line.
Risk and Safety Documentation
Records what the patient said about ideation, intent, and means, the protective factors you noted, and the safety plan you agreed on, with your clinical reasoning attached.
Medication History and Follow-up Notes
Keeps the medication trail straight: what was tried, what failed and why, the current dose, side effects, and the change you made today, without you retyping the list every visit.
A psychiatry note, captured in real time
An abridged med-management follow-up for depression and anxiety, drafted the way you would see it before signing.
34-year-old woman returning 6 weeks after starting sertraline 50 mg daily for major depressive disorder and generalized anxiety. Reports mood is somewhat improved, sleep has normalized to about 7 hours, and appetite has returned. Still describes morning anxiety and occasional racing thoughts before work. No nausea or sexual side effects. Adherent to the medication, takes it each morning. PHQ-9 today is 11, down from 18 at intake. GAD-7 is 9, down from 14. Denies suicidal ideation, intent, or plan; denies self-harm.
Appearance: well groomed, appropriate dress, good eye contact. Behavior: cooperative, no psychomotor agitation or retardation. Speech: normal rate and volume. Mood: "a little better." Affect: mildly constricted, congruent, reactive. Thought process: linear and goal-directed. Thought content: no suicidal or homicidal ideation, no delusions, no perceptual disturbances. Cognition: alert and oriented, attention and memory grossly intact. Insight and judgment: good.
1) Major depressive disorder, recurrent, moderate, partial response to sertraline at 6 weeks (PHQ-9 improved 18 to 11). 2) Generalized anxiety disorder, mild residual symptoms (GAD-7 9). Tolerating sertraline well with no adverse effects. Currently low acute risk: denies ideation, has protective factors including stable employment and family support.
Increase sertraline to 100 mg daily given partial response and good tolerability. Reviewed that full benefit may take another 4 to 6 weeks. Discussed sleep hygiene and started a brief daily worry-time exercise for the morning anxiety. Provided crisis line number and reviewed when to call. Continue current supportive therapy every 2 weeks. Repeat PHQ-9 and GAD-7 at next visit. Return in 4 weeks, sooner if mood worsens or any thoughts of self-harm emerge.
Illustrative example. Not a real patient encounter.
Built for psychiatry coding and your EMR
Notes capture the history you took, the mental status exam, the risk you assessed, and the time you spent, which is what backs your E/M level and any psychotherapy add-on. That is the detail an auditor looks for, and the first thing to slip when the note is finished from memory hours later.
- 90792Psychiatric diagnostic evaluation with medical services (new-patient intake)
- 99214 / 99215Established-patient E/M, moderate to high complexity med management
- 99214 + 90833E/M with 30-minute psychotherapy add-on, same session
- 90834Psychotherapy, 45 minutes with the patient
- 90837Psychotherapy, 60 minutes with the patient
- 90853Group psychotherapy (other than multiple-family group)
- F32.1Major depressive disorder, single episode, moderate
- F41.1Generalized anxiety disorder
- F43.10Post-traumatic stress disorder, unspecified
- F31.81Bipolar II disorder
- F90.2Attention-deficit hyperactivity disorder, combined type
Fits the workflow you already have
Drafts drop into the EMRs psychiatry and behavioral-health practices actually run on: Epic, Oracle Health (Cerner), athenahealth, and behavioral-health systems like Valant, ICANotes, and SimplePractice. You get the note type you are working in, an intake evaluation, a med-management follow-up, or a psychotherapy note. Psychotherapy notes stay separate from the general chart and remain in your control, so process notes are not folded into the record other clinicians read. It writes what you say; it does not diagnose for you or make the risk call.
What's Happening in Psychiatry
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Psychiatry AI scribe questions
Does it capture the mental status exam correctly?
How does it handle risk assessment and safety planning?
Can it document psychiatric drug names and dose changes?
The content is sensitive. How is patient information protected?
Does it connect to behavioral-health EMRs?
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