Psychiatric Evaluation Template: History, MSE and Formulation

Blank psychiatric evaluation template

The following headings are an original organizational aid. The American Psychiatric Association’s adult evaluation guidelines provide the broader clinical reference.

Encounter date, setting and participants:
Information sources, consent and limitations:
Presenting concern and patient priorities:
History of the current concern and functional impact:
Prior psychiatric care and treatment responses:
Current medicines, supplements, allergies and adverse effects:
Medical history and relevant available results:
Substance use history:
Family, developmental and social history:
Mental status examination: see prompts below
Safety assessment, supporting information and clinical reasoning:
Formulation and differential diagnosis:
Working diagnoses and remaining uncertainty:
Options discussed, preferences and agreed plan:
Follow-up, coordination and responsibilities:
Clinician review and signature:

Keep information sources visible. For example, distinguish the patient’s account from records reviewed and observations during this encounter. Record an unavailable history as unavailable; resolve discrepancies when possible.

Mental status examination prompts

Use these headings to document observations and elicited findings. Adjust the detail to what you assessed and describe the limitations of the encounter.

Appearance, behavior and engagement:
Psychomotor activity:
Speech:
Mood reported by the patient:
Affect observed:
Thought process:
Thought content and safety-related findings:
Perceptual experiences:
Cognition and any assessment performed:
Insight and judgment:
Assessment limitations:

Keep observations specific. Avoid copying findings forward without checking them. A symptom scale, a single checkbox, and this outline each capture only part of the information a clinician may need.

Connect the formulation to the plan

State the problem you are treating, the evidence supporting your working explanation, and the alternatives that remain under consideration. Record how patient preferences and relevant risks shaped the plan.

For each planned action, identify who will do it and how follow-up will occur. Name the information you still need and how it could affect the next decision.

Review the note before signing

• Confirm the patient, encounter date, participants and information sources.
• Check medicines, doses, allergies and copied text against information available for this encounter.
• Ensure the documented findings reflect the evaluation performed.
• Check that the formulation and plan explain the decisions recorded.
• Resolve contradictory statements and identify remaining uncertainty.

Noridian’s Medicare guidance distinguishes psychiatric diagnostic evaluation without medical services (90791) from evaluation with medical services (90792). It describes history, mental status, diagnosis and treatment planning among evaluation elements. Check the applicable payer policy for the actual service; this template does not determine coverage. Noridian mental health guidance.

Common questions

Can this template determine a diagnosis?

The headings organize documentation. Diagnosis and risk assessment require a clinician’s evaluation of the individual patient.

Should every mental status field be marked normal?

Document findings you actually assessed. Identify information that was unavailable or not assessed and record relevant limitations.

Does completing the template establish a billing code?

Code selection depends on the services performed, applicable rules, and payer requirements. A completed template alone cannot establish a code or guarantee payment.