Every note format behavioral health practices use.

The SOAP format is the workhorse of medical documentation, and most general AI scribes do a passable job with it. Behavioral health is where the wheels come off. A psychiatric SOAP note has to carry an MSE, a risk assessment, and a polypharmacy plan with monitoring instructions, and most generic templates fold all of that into a paragraph somewhere in the assessment. Auditors notice. Supervisors notice. The next clinician on the chart notices.

This template is the version we ship by default for psychiatrists, NPs, and PAs running med-management visits. It keeps the four sections every prescriber expects, and it surfaces the fields psychiatry actually charts inside them. Affect and thought process get their own labels in the objective section. Suicidality and homicidality have a structured field, not a sentence. Medication changes are tracked with reason, dose, and follow-up parameter, so a future visit can read the trajectory without reconstructing it.

Patient: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]     Provider: [provider_name]    Duration: [duration]

Subjective
- Chief complaint (in patient's own words):
- History of present illness (interval since last visit, symptom course, sleep, appetite, energy, concentration, anhedonia, anxiety, panic, mood reactivity):
- Medication adherence and side effects:
- Substance use update:
- Stressors, supports, recent life events:
- Patient goals for this visit:

Objective
- Vitals (if obtained):
- Mental Status Exam
  - Appearance and behavior:
  - Speech:
  - Mood (patient-reported):
  - Affect (clinician-observed):
  - Thought process:
  - Thought content:
  - Perceptions:
  - Cognition and insight:
  - Judgment:
- Risk assessment
  - Suicidal ideation (passive/active, plan, intent, means, prior attempts):
  - Homicidal ideation:
  - Risk factors:
  - Protective factors:
  - Clinical risk impression:

Assessment
- Primary diagnosis (with ICD-10):
- Secondary or comorbid diagnoses:
- Diagnostic clarification (rule-outs, deferred diagnoses):
- Clinical formulation (interval response to treatment, residual symptoms):

Plan
- Medication continued:
- Medication changes (drug, dose, reason, monitoring parameter):
- Therapy referral or coordination:
- Labs ordered (lithium level, lipid panel, TSH, CBC, CMP, drug screen, etc.):
- Safety planning if relevant:
- Patient education provided:
- Follow-up interval:

How Nextvisit fills this. AriaMD listens for the structural cues a psychiatric visit follows and routes content into the right field as it hears it. The mood the patient says lands in mood. The affect you observe lands in affect. A statement of suicidal ideation does not get paraphrased into the HPI, it lands in the risk field with the framing the patient used. Medication changes track the reason and the monitoring parameter, so the next visit’s chart already shows what to follow. Direct quotes are preserved when they carry clinical meaning. You sign the note. You own the diagnosis. The work that goes away is the structural reassembly between the visit and the chart.

DAP is the format most therapists and counselors default to once they have written a few hundred notes. Data, Assessment, Plan reads short and clean, but a useful DAP note for behavioral health needs more shape than three boxes. The intervention has to be specific enough to read like clinical work, the response has to be observed and tied to the intervention, and the treatment-plan goal it advances has to be named. Generic AI scribes tend to flatten therapy into a session recap, which is not a clinical note.

This template is what we ship for therapists on the Therapy plan and for counselors inside larger groups. It fits a 45 to 60 minute psychotherapy visit, and it works for CPT 90837 and 90834 documentation. The fields surface what an audit would expect to see, including the modality used, the intervention delivered, the patient response, and the next-session plan, without reading like a discharge summary.

Client: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]    Clinician: [provider_name]    Duration: [duration]
CPT (likely): [cpt_code]  Modality: [therapy_modality]

Data
- Presenting concern this session:
- Mood and affect at start of session:
- Recent stressors and life events since last visit:
- Symptoms reported (sleep, appetite, anxiety, depressive content, panic, dissociation, etc.):
- Substance use update:
- Risk indicators (SI, HI, self-harm urges, recent behavior):
- Direct client statements (verbatim where clinically relevant):

Assessment
- Treatment-plan goal addressed this session:
- Therapeutic intervention used (CBT cognitive restructuring, DBT skill, EMDR phase, IFS parts work, motivational interviewing, etc.):
- Specific technique applied:
- Client response to intervention (engagement, resistance, insight, affect shift):
- Progress toward goal (improving, plateau, regression, with rationale):
- Updated clinical impression (DSM-5-TR or ICD-10):

Plan
- Skill or assignment for between sessions:
- Risk plan if applicable:
- Coordination with prescriber, school, family:
- Modality or frequency change considered:
- Next session focus:
- Next appointment:

How Nextvisit fills this. AriaMD recognizes therapy structure and routes content into the right field. The intervention you named in session lands in the intervention field, with enough specificity to support the CPT code. The client response is captured as observed, not paraphrased. Verbatim statements that carry clinical weight are preserved with speakers labeled. The treatment-plan goal you opened the session on is matched to the work you did, so progress tracks visit over visit. Counselors keep ownership of the assessment and the plan. The reassembly work goes away.

BIRP is the format agencies, community mental health centers, and supervised LCSW or LMFT settings tend to require. Behavior, Intervention, Response, Plan looks similar to DAP at first glance, and the difference matters in audit. BIRP demands observation. The behavior is what the clinician saw and heard in the room, not what the client described later. The intervention is the specific technique applied, named in clinical language. The response is observed. The plan is concrete and tied to the treatment plan.

This template is built for agency settings, supervised pre-licensure practice, and any group that bills through a payer that audits BIRP-format notes. It supports session documentation for individual, group, and family work. The fields are tight on purpose. A BIRP note that reads like a recap will not survive a Medicaid audit, and a BIRP note that reads like a chart entry will.

Client: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]    Clinician: [provider_name]    Supervisor: [supervisor_name]
Duration: [duration]      Session type: [session_type]    CPT: [cpt_code]
Treatment-plan goal addressed: [goal_id_or_text]

Behavior
- Observed presentation (appearance, eye contact, motor activity, engagement):
- Affect and mood as observed in session:
- Speech and thought process observed:
- Behavioral incidents during session (crying, agitation, dissociation, withdrawal):
- Reported symptoms in client's own words:
- Risk-relevant statements or behavior in session:

Intervention
- Therapeutic modality used:
- Specific intervention or technique delivered:
- Skill taught or rehearsed:
- Psychoeducation provided:
- Coordination of care during session (school, prescriber, caregiver):

Response
- Engagement with intervention (participation, affect shift, insight):
- Skill demonstration in session:
- Resistance, deflection, or rupture and how it was addressed:
- Verbal feedback from client:
- Functional change observed by end of session:

Plan
- Between-session task or skill practice:
- Safety plan or crisis response if indicated:
- Coordination needed before next session:
- Next session focus and modality:
- Frequency adjustment considered:
- Next appointment date:
- Supervision review needed: yes / no

How Nextvisit fills this. AriaMD listens for observation versus self-report and tags content accordingly. What the client said about the week lands in behavior under reported symptoms. What you saw in session lands in behavior under observed presentation. The intervention you named in session is captured with the technique-specific language an auditor expects. Response is recorded as observed change in affect or skill demonstration, not as a generic engagement note. Supervisor name carries through for pre-licensure documentation. The clinician signs and owns the chart. The structure work is what goes away.

A new-patient psychiatric intake is the longest, densest piece of documentation a prescriber writes. Sixty minutes of conversation has to become a chart that another clinician, a payer auditor, and a future version of the prescriber can all read and act on. Most general AI scribes produce a clean four-paragraph summary and call it an intake. That is not an intake. It is a recap.

This template is the comprehensive intake we ship for psychiatrists, psychiatric NPs, and PAs running their own panels. It covers what the field expects in a new-patient evaluation: chief complaint and HPI, full psychiatric history including hospitalizations and prior medication trials with response, family psychiatric history, social and developmental history relevant to presentation, substance use, MSE, formal risk assessment with documented factors, differential diagnosis with reasoning, and a treatment plan with monitoring. It is sized for a 45 to 60 minute visit and supports CPT 90792.

Patient: [patient_name]    DOB: [dob]    Age: [age]    Gender: [gender]
Date: [encounter_date]     Provider: [provider_name]    Duration: [duration]
Referral source: [referral_source]    Pronouns: [pronouns]

Chief complaint (in patient's own words):

History of present illness
- Onset, course, severity, frequency:
- Triggers and precipitants:
- Modifying factors:
- Current symptoms (depression, anxiety, panic, mania, psychosis, sleep, appetite, concentration, anhedonia):
- Functional impact (work, school, relationships, self-care):

Past psychiatric history
- Prior diagnoses:
- Hospitalizations (date, facility, reason, length of stay):
- Suicide attempts and self-harm history:
- Prior medication trials (drug, dose, duration, response, reason discontinued):
- Prior therapy and modality:
- ECT, TMS, ketamine, Spravato history:

Substance use history
- Current use (alcohol, cannabis, stimulants, opioids, benzodiazepines, tobacco, other):
- Pattern, quantity, last use:
- Past treatment for SUD:

Past medical history and surgeries:

Allergies and current medications (psychiatric and non-psychiatric):

Family psychiatric and medical history:

Social and developmental history
- Childhood and developmental milestones:
- Trauma history (screened with patient consent):
- Education and occupation:
- Relationships and supports:
- Legal history:
- Military history:

Mental Status Exam
- Appearance and behavior:
- Speech:
- Mood and affect:
- Thought process and content:
- Perceptions:
- Cognition, insight, judgment:

Risk assessment
- Suicidal ideation, plan, intent, means:
- Homicidal ideation:
- Self-harm urges or behavior:
- Risk factors:
- Protective factors:
- Clinical risk impression:

Diagnostic impression and differential (with ICD-10):

Treatment plan
- Medication recommendation (drug, starting dose, titration plan, monitoring):
- Therapy recommendation and referral:
- Labs and baseline studies ordered:
- Safety planning:
- Coordination with PCP or other providers:
- Patient education and informed consent documented:
- Follow-up interval:

How Nextvisit fills this. AriaMD listens for the structural cues a psychiatric intake follows and routes content into the right field as it hears it. The MSE lands in the MSE. Risk lands in risk, with the framing the patient used. A prior medication trial that the patient mentions in passing is captured with the dose, duration, and reason for discontinuation. Direct quotes are preserved in the chief complaint and anywhere a paraphrase would lose meaning. The draft is ready by the time the patient leaves the room. You review, edit, and sign. The structural reassembly between a sixty-minute visit and a complete intake is what goes away.

Spravato (esketamine) sessions live under a REMS program, and the documentation reflects that. Every session needs vitals before and after, a documented two-hour observation period, an assessment of dissociation and sedation, vitals released before discharge, and a transportation plan. Generic SOAP templates do not capture this well. Practices end up writing the structure by hand on a paper checklist and then hand-keying it into the EHR after the patient leaves.

This template is what we ship for Spravato-certified clinics. It is built around the REMS observation requirements and the documentation a payer audit will look for. It works for both 56 mg and 84 mg dose visits, induction phase and maintenance. Pre-dose vitals, dose given, observation interval vitals, dissociation screening (CADSS-style if used), sedation assessment, and the post-observation discharge criteria all carry their own structured fields.

Patient: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]     Provider: [provider_name]    Monitor: [monitor_name]
REMS pharmacy: [pharmacy_name]    Visit number in series: [visit_number]
Treatment phase: induction (twice weekly) / maintenance (weekly or biweekly)

Pre-treatment
- Indication: treatment-resistant depression / MDD with suicidal ideation
- Concurrent oral antidepressant (drug, dose):
- Last dose date and time:
- Patient screening since last visit (BP, mood, SI, recent substance use, recent BP medication change):
- Pre-dose vitals (BP, HR, time):
- Pre-dose mood rating and PHQ-9 if collected:
- Informed consent on file and reaffirmed: yes / no
- Transportation arranged: yes / no
- NPO status for the morning: yes / no

Treatment
- Dose given: 56 mg / 84 mg
- Devices used and observed self-administration: yes / no
- Time of first device:
- Time of second device (if applicable):

Observation period (minimum two hours from last dose)
- 40-minute interval BP and HR:
- 90-minute interval BP and HR:
- 120-minute interval BP and HR:
- Dissociation observed (CADSS or clinical impression):
- Sedation observed (RASS or clinical impression):
- Adverse effects (nausea, headache, vertigo, BP elevation, anxiety):
- Interventions during observation:

Post-observation
- Final vitals before discharge (BP, HR, time):
- Mental status at discharge (alert, oriented, ambulating safely):
- Suicidal ideation reassessment:
- Dissociation resolved: yes / no
- Sedation resolved: yes / no
- Discharge criteria met per REMS: yes / no
- Released to (responsible adult):
- Transportation method (no driving for the rest of the day):

Assessment and plan
- Treatment response (interval since last session, depression scale change, functional change):
- Side-effect tolerability:
- Continue current dose: yes / no
- Dose adjustment recommendation:
- Next session scheduled:
- Continuation of oral antidepressant confirmed:
- Coordination with referring prescriber:

How Nextvisit fills this. AriaMD captures the session as it runs. Pre-dose vitals, the dose given, and the observation-interval vitals land in their own fields. Dissociation and sedation observations are tagged at the time-stamps they occurred. Discharge-criteria language matches what a REMS audit expects. The note routes by default to the patient’s existing chart with the Spravato custom tag, so the visit is filterable in the longitudinal view alongside the rest of the treatment course. The clinician reviews, edits, and signs. The paper checklist goes away.

TMS (repetitive transcranial magnetic stimulation) is a course-based therapy. A typical induction protocol runs 30 to 36 sessions over six to nine weeks, with the documentation expectation that every session is recorded with the treatment parameters, side effects, and a response trend. Payers reauthorize across the course. A loose chart that captures only the first and last visits will not survive a medical-necessity review.

This template is built for TMS-certified psychiatry practices running standard FDA-cleared protocols (high-frequency left DLPFC for MDD, deep TMS for MDD or OCD, theta-burst, and accelerated). It supports the initial mapping visit, every treatment session, and the periodic depression-scale checkpoints (PHQ-9 every five sessions is common). The fields are sized for the short treatment visit, since most sessions are 20 to 40 minutes including setup.

Patient: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]     Provider: [provider_name]    Operator: [operator_name]
Device: [tms_device]       Coil: [coil_type]
Session number: [session_number] of [total_sessions]
Protocol: high-frequency left DLPFC / deep TMS / iTBS / accelerated

Pre-session
- Interval mood and side-effect review:
- Sleep, headache, scalp discomfort since last session:
- Adherence to oral antidepressant if applicable:
- Recent seizure-threshold concerns (medication change, sleep deprivation, alcohol, stimulants):
- Vitals if obtained:
- PHQ-9 / HAM-D / IDS-SR if checkpoint session: [score]

Motor threshold (repeat or weekly recheck)
- Method (visual, EMG):
- Resting motor threshold percentage:
- Treatment intensity (percentage of MT):

Treatment parameters
- Frequency (Hz):
- Train duration (sec):
- Inter-train interval (sec):
- Number of trains:
- Pulses per train:
- Total pulses delivered this session:
- Coil location (F3, beam-F3, deep H1, other):
- Treatment time (min):

During session
- Patient tolerance:
- Pain or discomfort rating (0 to 10):
- Adjustments made (intensity reduction, repositioning):
- Adverse events (twitching, nausea, near-syncope, none):

Post-session
- Headache or scalp discomfort post-session:
- Mood reported by patient post-session:
- Discharge ambulation:
- Driving cleared (no contraindication this session): yes / no

Course response trending
- Depression scale trend across course:
- Functional change reported by patient:
- Side effect pattern across course:

Plan
- Continue protocol as scheduled: yes / no
- Parameter adjustment for next session:
- Next session date:
- Reauthorization checkpoint approaching: yes / no
- Anticipated taper or maintenance schedule:

How Nextvisit fills this. AriaMD captures the parameters the operator dictates during setup, the patient’s interval review, and the during-session events. Motor threshold and intensity carry through across sessions, so the chart shows the parameter change history without the operator hand-entering it. PHQ-9 or HAM-D scores tag the session as a checkpoint and feed the course-response trend. The Active TMS custom tag keeps the cohort filterable, so a clinic with 40 patients on simultaneous courses can pull every active patient with one filter. The provider signs the note. The course-level documentation reassembles itself.

MAT (medication-assisted treatment) documentation has its own shape. A visit for buprenorphine induction looks different from a methadone clinic visit, and both look different from a naltrexone follow-up. All three carry regulatory documentation requirements that go beyond a standard SOAP, including counseling referral, urine drug screen results, withdrawal scoring at induction, and the adherence narrative that supports continued prescribing. A generic AI scribe will miss most of this.

This template is built for addiction-medicine practices and psychiatrists with X-waivers (now sunset, but the documentation discipline persists). It supports buprenorphine induction and maintenance, naltrexone (oral and Vivitrol), and methadone-clinic follow-up. The fields cover the COWS or CINA score at induction, the UDS results in the assessment rather than buried in a lab tab, the counseling and behavioral-health referral coordination, and the controlled-substance documentation a DEA review would expect.

Patient: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]     Provider: [provider_name]    Duration: [duration]
Substance use disorder diagnosis: [icd10]
MAT medication: buprenorphine / buprenorphine-naloxone / methadone / naltrexone (PO) / naltrexone (Vivitrol)
Phase: induction / stabilization / maintenance / taper

Subjective
- Last use date (alcohol, opioids, stimulants, benzodiazepines, cannabis, other):
- Cravings (frequency, intensity, triggers):
- Withdrawal symptoms since last visit:
- Adherence to MAT medication:
- Side effects:
- Counseling and behavioral-health engagement:
- Recovery support engagement (NA, AA, SMART, peer support):
- Stressors and recent life events:
- Legal, employment, family update:

Objective
- Vitals:
- COWS or CINA score (induction or as clinically indicated):
- Pinpoint pupils, diaphoresis, tremor, other physical findings:
- Mental status exam:
- UDS results (this visit and trend):
- Confirmatory testing if performed:
- PDMP review documented: yes / no
- Date of last PDMP query:

Risk assessment
- Overdose risk:
- Naloxone in home: yes / no
- Suicidal or self-harm ideation:
- Concurrent prescribed CNS depressants:
- Pregnancy status if applicable:

Assessment
- Treatment response (engagement, abstinence, harm reduction):
- Diagnostic clarification:
- Co-occurring psychiatric conditions:
- Risk and protective factors update:

Plan
- Medication continued (drug, dose, formulation):
- Dose adjustment (with rationale):
- Prescription written: days supply, refills, pharmacy:
- Counseling and behavioral-health referral status:
- Naloxone prescribed or refilled: yes / no
- UDS frequency for next interval:
- Labs (LFTs for naltrexone, hepatitis screening, HIV screening as indicated):
- Safety planning:
- Follow-up interval:
- Coordination with PCP, OB, criminal-justice supervision:

How Nextvisit fills this. AriaMD captures the MAT-specific data points during the visit and routes them into the right field. The COWS score at induction lands in the COWS field, not paraphrased into the assessment. UDS results dictated by the operator are tagged to the visit and pull into the trend view. PDMP query confirmation is logged. The MAT custom tag keeps the cohort filterable for clinic-level reporting. Buprenorphine and naltrexone variants each pull their own field set, so a Vivitrol injection visit does not surface buprenorphine-specific fields. The provider signs the note. The regulatory paperwork is documented in the same chart, not in a parallel folder.

Patients on long-term lithium need monitoring that does not fit a generic med-management note. Serum levels trend across visits. Renal function (creatinine, eGFR) and thyroid (TSH) need periodic review. Side effects (tremor, polyuria, weight change, cognitive blunting) shift over time and have to be tracked at each visit, because the dose-adjustment decision is rarely about a single number, it is about the trend. A general SOAP note flattens that picture.

This template is built for psychiatrists and psychiatric NPs maintaining patients with bipolar disorder on lithium. It surfaces the level history, the lab interval, and the side-effect trajectory in their own fields. It works for the brief 20 minute med check that a stable patient on lithium typically gets, and it scales to a longer visit when levels are out of range or a new side effect appears. The Lithium custom tag keeps the patient panel filterable for clinic-level lab cycle management.

Patient: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]     Provider: [provider_name]    Duration: [duration]
Diagnosis: [icd10] (bipolar I, bipolar II, schizoaffective, augmentation for MDD)
Lithium formulation and dose: immediate-release / extended-release, total daily dose
Years on lithium: [years_on_lithium]

Subjective
- Mood interval (euthymic, depressive, hypomanic, mixed):
- Sleep, energy, concentration, racing thoughts:
- Adherence (missed doses, timing, with food):
- Lithium side effects:
  - Tremor (fine, coarse, functional impact):
  - Polyuria, polydipsia, nocturia:
  - Weight change:
  - GI symptoms (nausea, diarrhea):
  - Cognitive complaints (slowing, word-finding):
  - Cutaneous (acne, psoriasis):
  - Hypothyroid symptoms (cold intolerance, fatigue, weight gain):
- NSAID, ACE inhibitor, ARB, diuretic, dehydration, fever, low-sodium diet (interaction risks):
- Recent illness or hospitalization:
- Substance use:
- Pregnancy status if applicable:

Objective
- Vitals (BP, HR, weight):
- Mental status exam:
- Tremor exam if performed:
- Lithium level
  - Most recent: [level] mEq/L  Drawn: [draw_time]  Trough timing confirmed: yes / no
  - Trend across last four levels:
- Recent labs
  - Creatinine, BUN, eGFR (with trend):
  - TSH (with trend), free T4 if indicated:
  - Calcium (PTH if indicated):
  - CBC, electrolytes, urinalysis if indicated:
- Last ECG (if older patient or new cardiac symptom):

Risk assessment
- Suicidal ideation:
- Toxicity risk indicators (level approaching 1.2, dehydration, recent NSAID start):

Assessment
- Mood stability across interval:
- Lithium therapeutic range adequacy:
- Renal trajectory:
- Thyroid status:
- Side-effect tolerability:
- Diagnostic update if any:

Plan
- Lithium dose continued:
- Lithium dose adjustment (with rationale and target level):
- Next lithium level: [date]
- Next renal panel and TSH: [date]
- Other labs ordered:
- Concurrent medications continued or adjusted:
- Patient education (hydration, NSAIDs, sodium intake, illness sick-day rules):
- Coordination with PCP for renal and thyroid:
- Safety planning if relevant:
- Follow-up interval:

How Nextvisit fills this. AriaMD pulls the lithium level and the renal and thyroid trends from the chart and surfaces them in the visit note, so the dose decision references the trend rather than a single value. Side-effect language is captured as the patient describes it and routed into the right field, not collapsed into a single line. Interaction risks (a recent NSAID start, a new ACE inhibitor, a low-sodium diet) get flagged when the conversation surfaces them. The Lithium custom tag keeps the panel filterable for the lab-cycle review most clinics run quarterly. The provider signs the note. The trend reassembly is what goes away.

Group therapy generates one of the most awkward documentation problems in behavioral health. The session is one event, but the chart obligation is per member. A 90-minute DBT skills group with eight participants is one therapist’s afternoon and eight separate progress notes by the end of the day. Most clinicians end up writing the group focus once and copy-pasting it across eight charts, then handwriting in the participation differences. That copy-paste workflow is brittle, slow, and exactly what an audit will pick at.

This is a Custom-format template built for LCSW and LPC group settings, including DBT skills groups, IOP and PHP groups, substance-use process groups, and supervised pre-licensure groups. It splits the documentation into a shared group block (focus, intervention, group dynamics) and a per-member block (participation, response, individual treatment-plan progress, risk update). The shared block writes once, the per-member block fills per participant, and each participant’s chart receives a complete note that does not look templated.

Group session
- Date: [encounter_date]
- Facilitator(s): [provider_name] / [co_facilitator_name]
- Supervisor: [supervisor_name]
- Modality: DBT skills / CBT / process / psychoeducation / SUD relapse prevention / other
- Group format: open / closed
- Total members in attendance: [count]
- Duration: [duration]
- CPT (typical 90853 for group psychotherapy):

Shared group block (writes once)
- Group focus and topic:
- Curriculum or skill module covered (if applicable):
- Intervention or technique delivered:
- Group dynamic observed (cohesion, conflict, supportive interactions):
- Co-facilitation roles if applicable:
- Safety incidents during group: yes / no, with description if yes:

Per-member block (writes for each participant)

Member: [patient_name]    DOB: [dob]    Age: [age]    Member ID in group: [member_id]
- Treatment-plan goal addressed for this member:
- Attendance: present full / present partial / absent
- Affect and presentation in group:
- Participation level (engaged, observer, withdrawn, disruptive, supportive):
- Specific contributions or disclosures:
- Skill demonstration or practice in session:
- Response to intervention:
- Risk update (SI, HI, self-harm, substance use disclosure):
- Coordination needed with primary therapist or prescriber:
- Plan for next session or individual contact:
- Supervisor co-sign required (pre-licensure): yes / no

How Nextvisit fills this. AriaMD captures the group session as a single event and splits the documentation across each participant’s chart automatically. The shared block (focus, intervention, group dynamics) writes once. The per-member block uses speaker identification from the audio to attribute participation, disclosures, and skill demonstration to the right member, so each member’s chart gets a real note rather than a copy-paste. Pre-licensure supervisor co-sign routes through the supervisor field. CPT 90853 is suggested by default. The group facilitator signs each member note individually. The eight-charts-from-one-session reassembly work goes away.

Not every visit needs a full SOAP. A stable patient on a steady medication regimen, doing well, calling in for a 15-minute video check-in does not generate the same chart as a 60-minute new-patient intake. Forcing the longer format on a brief visit produces inflated notes, wasted clinician time, and audit risk that runs in the other direction ( documentation that does not match the level of service billed). The brief telehealth follow-up needs its own shape.

This is a Custom-format template built for low-acuity telehealth follow-ups across psychiatry, therapy, and primary-care behavioral health integration. It works for video and audio-only visits where state law allows, supports the place-of-service and modifier documentation telehealth audits review, and right-sizes the note for the actual visit. Common CPT codes covered are 99213 and 99214 with modifier 95 for video, and 90832 for brief therapy.

Patient: [patient_name]    DOB: [dob]    Age: [age]
Date: [encounter_date]     Provider: [provider_name]    Duration: [duration]
Visit type: video / audio-only (with state-law justification)
Place of service code: [pos_code]    Modifier: [modifier]
Patient location at time of visit: [city, state]
Provider location at time of visit: [city, state]
Patient consent for telehealth confirmed this visit: yes / no
Identity verified: yes / no    Verification method:

Subjective
- Reason for follow-up:
- Interval since last visit (key changes):
- Medication adherence and side effects:
- Symptom check (mood, sleep, anxiety, panic, energy, appetite, focus):
- Substance use update:
- Psychosocial stressors:
- Patient questions or concerns:

Objective
- Mood and affect (as observed on video):
- Speech:
- Engagement and orientation:
- Visible distress, agitation, intoxication, or safety concerns on screen:
- No physical exam (telehealth) / vitals patient-reported:

Risk assessment
- Suicidal ideation:
- Homicidal ideation:
- Acute safety concerns:
- Local emergency contact and address verified for the visit: yes / no

Assessment
- Diagnosis (continued):
- Clinical impression (stable / improving / worsening):

Plan
- Medication continued:
- Medication changes (drug, dose, reason, monitoring):
- Prescription sent (e-prescribed to: [pharmacy_name]):
- Refills authorized:
- Therapy or referral coordination:
- Labs ordered (with local lab if needed):
- Patient education provided:
- Next visit (telehealth or in-person):
- Follow-up interval:
- Clinician available for urgent contact between visits via:

How Nextvisit fills this. AriaMD captures the brief follow-up at the right size. Patient location, provider location, and consent for the telehealth visit are surfaced in their own fields, since these are the items state-by-state telehealth audits actually look for. The mood and affect section is captured as observed on video, with a note that no physical exam was performed. E-prescribing details flow into the plan. The visit can be filed against the patient’s longitudinal chart so the trend view does not lose the visit just because it was a short one. The clinician signs. The structural rebalance between brief and full notes goes away.