Psychiatry consult note template with examples

How to write a psychiatry consult note, step by step

1. State the consultation question in the first lines. 'Referred for depression' is a topic; 'Assess capacity to consent to discharge planning' is a question you can answer.
2. Take the history of present symptoms in the patient's timeline, not the referral letter's. Onset, course, triggers, prior response to treatment, and what changed to prompt referral now.
3. Complete the past psychiatric history even when it is empty. 'No prior diagnoses, admissions, attempts, or treatment' is information; a blank section is an omission.
4. Examine and record mental status as observed today: appearance, behaviour, speech, mood and affect, thought content and process, perception, cognition, insight, and judgment.
5. Write risk as its own section. Suicidal and homicidal ideation, plan, intent, access to means, past behaviour, and protective factors, with a formulation of what would raise or lower risk.
6. Formulate before you diagnose. A short biopsychosocial formulation explains why this patient, why now, and keeps the differential honest.
7. Split the plan into safety, biological, and psychosocial items, and give every recommendation an owner and a timeframe.
8. Close with what the referring team should do, what you will do, and when each will happen. A consult that ends without follow-up ownership has not finished its job.

Blank psychiatry consult template

Reason for consultation / question asked:
Chief complaint (patient's words):

History of present symptoms:
Past psychiatric history (diagnoses, admissions, suicide attempts, treatments and response):
Past medical history:
Medications (psychiatric and other, with adherence):
Allergies:
Substance use:
Social history (housing, work, supports, legal):
Family psychiatric history:
Review of systems:

Mental status examination:
Appearance / behaviour / speech / mood / affect:
Thought content (SI, HI, paranoia, obsessions):
Thought process / perception / cognition / insight / judgment:

Risk: suicide / self-harm / harm to others / vulnerability, with protective factors:
Diagnostic assessment and formulation:
Differential diagnosis:
Psychiatric diagnosis:
Psychological testing (if any):

Treatment plan — Safety:
Treatment plan — Biological (medications, investigations, medical workup):
Treatment plan — Psychosocial (therapy, supports, social needs):
Medication changes made today:
Psychotherapy recommendations:
Prognosis:
Follow-up plan and who owns each item:
Patient education provided:
Recommendations to the referring team:
Referrals recommended:

Example: consultation-liaison, post-MI low mood

Reason for consultation: Assess mood and capacity to participate in cardiac rehab planning.

History of present symptoms: Tearful since day 1, sleeping 3–4 h with early waking, eating half portions. Denies anhedonia before admission; says he is frightened he will "die on the treadmill." No prior depressive episodes. No SI; says he wants to see his granddaughter married in June. Wife visits daily.

Past psychiatric history: None. No admissions, no attempts, no prior treatment.
Medications: ASA, ticagrelor, metoprolol, atorvastatin, ramipril. Adherent pre-admission.
Social: Retired electrician, lives with wife, independent ADLs.

MSE: Pleasant, cooperative. Speech normal rate. Mood "scared, mostly." Affect constricted, tearful when discussing rehab, brighter with wife. No paranoia. Cognition intact to bedside testing. Insight good.

Risk: Denies SI/HI, no plan or intent. Protective: wife, future-oriented. Risk low today; main risk is avoidance of rehab, not self-harm.

Assessment: Adjustment disorder with anxious and depressed mood after a life-threatening cardiac event, not major depression at this point. Fear of exertion is maintaining withdrawal from rehab.

Plan — Safety: No holds or enhanced observation. Nursing to flag new hopelessness statements.
Plan — Biological: No antidepressant today. Recheck mood at 2 weeks; if PHQ-9 remains ≥10 with anhedonia, cardiology and family doctor to consider sertraline (check QTc and bleeding risk on dual antiplatelets first).
Plan — Psychosocial: Cardiac rehab team to grade first sessions with heart-rate targets shown to him in writing. Offer cardiac psychology referral. Wife included in discharge teaching.
Follow-up: I will review once more before discharge. Referring team: please send PHQ-9 at the 2-week cardiology follow-up.

Who uses a psychiatry consult note, and when

Psychiatrists write consult notes in hospital consultation-liaison services, emergency departments, and outpatient clinics; family physicians and nurse practitioners use the same structure for mental-health assessments and shared-care referrals.

• Emergency department assessments where risk and disposition must be defensible the same day.
• Inpatient consultation-liaison requests from medical and surgical teams.
• Outpatient diagnostic assessments that will anchor months of treatment.
• Shared-care advice letters back to primary care with a concrete monitoring plan.
• Capacity, safety, and follow-up documentation after crisis presentations.

Documentation, privacy, and record-keeping in Canada

A psychiatry note often becomes the record relied on in capacity disputes, involuntary-admission reviews, and coroner or college inquiries. Document the mental status examination in observed terms, quote the patient's own words for suicidal or homicidal ideation, and record the reasoning behind risk formulation — not just a low/moderate/high label. In Canada, provincial mental-health legislation governs detention and review rights, while health-privacy law (for example PHIPA in Ontario and PIPEDA federally) governs consent and disclosure; duty-to-warn and child-protection reporting duties override confidentiality in defined circumstances.

Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.

Common mistakes that weaken a psychiatry consult note

• Recording 'denies SI' with no quoted words, context, or protective factors.
• Writing a risk label (low/moderate/high) with no formulation or time frame.
• Omitting collateral history in psychosis, mania, or cognitive presentations.
• Listing a diagnosis with no biological, psychological, and social plan.
• Copying forward a stale mental status examination from a previous visit.
• Starting or changing psychotropics with no monitoring, consent discussion, or follow-up date.

What separates a consult from a progress note

• It names the question it was asked. If the referrer asked about capacity, the note says so and answers it.
• Risk gets its own lines, with protective factors, not a single 'denies SI/HI' in the MSE.
• The plan is split safety / biological / psychosocial, the same split Scribeberry's Psychiatry Consult generates, so the ward team can act on each part.
• Every recommendation has an owner: you, the referring team, or the family doctor. 'Consider referral' with no owner is where consults go to die.
• Unknowns stay visible as 'Not provided' instead of being silently normalized.

Consult note vs progress note vs therapy note

Using the wrong frame produces the most common consult defect: a long progress note that never answers the referral question. If a section does not help the referring team decide or act, it belongs in a different note.

Example 2: emergency department, first-episode psychosis screen

Reason for consultation: Assess for psychosis and admission criteria after 5 days of escalating paranoia.

History of present symptoms: Family reports he stopped sleeping 5 nights ago, quit his warehouse job believing coworkers were recording him, and was found barricading his apartment door. No prior psychiatric contact. Cannabis daily for 3 years, increased recently; family unsure about other substances. Eating little. No SI; told his sister "they will have to take me first," no plan or identified target.

Past psychiatric history: None known. No admissions, no attempts, no treatment.
MSE: Dishevelled, pacing, guarded. Speech rapid and difficult to interrupt. Mood "wired." Affect labile. Thought content: persecutory delusions, ideas of reference. Thought process tangential. Perception: reports hearing coworkers commenting through walls, not testable here. Cognition grossly intact. Insight absent; judgment impaired.

Risk: No expressed SI/HI with plan or intent, but unpredictable behaviour driven by persecutory beliefs, severe sleep deprivation, and no insight. Risk to others is conditional on perceived threat; risk to self mainly through neglect and escalation. Protective: engaged family, no access to firearms confirmed by sister.

Assessment: First-episode psychosis, substance-induced versus primary psychotic disorder not yet separable; cannabis is a contributor to clarify, not a conclusion. Medical causes not yet excluded.

Plan — Safety: Admit under provincial mental health legislation as certified; constant observation overnight; reassess voluntariness in the morning.
Plan — Biological: CBC, electrolytes, TSH, urine drug screen, and CT head as ordered by ED; hold antipsychotic decision until medical screen returns and I re-examine, expected within 12 hours.
Plan — Psychosocial: Sister is contact for collateral; social work to address job and housing letters only after stabilization.
Follow-up: I will review in the morning and document diagnosis, medication plan, and disposition. Referring ED team: please flag any aggression or attempt to leave overnight.

Frequently asked questions

References

1. Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
2. Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
3. Personal Health Information Protection Act (PHIPA) — Government of Ontario
4. Clinical practice and position papers — Canadian Psychiatric Association
5. Mental health information and clinical resources — Centre for Addiction and Mental Health (CAMH)
6. Mental Health Act (Ontario) — Government of Ontario

Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.