How to Write a Great Psych Note as a NP

Psych. Even if that is not your specialty as a Psychiatric Mental Health Care Nurse Practitioner (PMHC NP), you will see see it in every setting. Learning how to write a great psych note as a NP will enhance your services, make a more accurate note in the patient’s chart and help you offer great options that could be lifesaving.

Mental Health

Mental health is a hugely important factor in wellness – for your patients and for you.

Knowing how to chart effectively will be an important skill.

You want your charts to reflect:

• An accurate picture of what is going on with the client
• Demonstrate an understanding of how to rate and scale using EBP tools
• Address the main areas of safety and concern
• Highlight the individual treatment chosen for the client
• Show a medical decision making model that satisfies payer (insurance) requirements
• Gives you a great set of differentials to help guide treatment and lead to better patient outcomes
• Keeps you from getting sued

That last one is just plain. honest. truth.

You want to do right by the client and by yourself and be able to serve another client on another day.

If you are reading this post, you may notice that “patient” and “client” are used interchangeably.

Most of my FNP friends have “patients” and my PMHC NP colleagues have “clients”.

However you address their title, these are people who have come to you in a moment of need of assistance for a better balance in their mental health.

How Do You Write a Great Psych Note as a NP?

There are basics to every note that should not be skipped here. If your EMR doesn’t do it for you – you need to make sure the date and time of the visit are correct. You also need to indicate if the visit was face to face or telehealth to meet requirements for payer sources.

If vitals are collected, those need recorded.

A key note on vitals: remember that a lot of the mental health medications can lead to weight gain and factors that may contribute to metabolic syndrome.

It is important that if you are doing telehealth that you bring the client in for a face to face visit periodically to collect this data. You can also instruct the client on how to assess some of these measures and self report.

Don’t forget to also review:

• Health History
  • Includes medical, surgical, reproductive
  • Ask about family history – this is important as some physical and mental health issues have a genetic component and you don’t want to miss an important clue
  • Cancer history, family cancer history, risk factors
• For Females of Child Bearing Age it is Important to Ask About Pregnancy and Pregnancy Prevention
  • You can refer them to an OBGYN appointment, if needed, before starting some medications that could be potentially harmful to the developing baby
  • You can also have a pregnancy test done prior to initiating some medications
  • Ensuring there is a method of birth control utilized is prudent for some psychopharmacological therapies
• Smoking History
• Current Medications Prescribed by Health Care Providers
• Alternative and Over the Counter Drug Use / Therapies
• IV or other Illicit Drug Use
• Alcohol Use
  • With both drug and alcohol use, the route, amount, frequency and name should be recorded
  • Resources for cessation of smoking, drug and alcohol use should be offered and recorded in the HPI
• Psychiatric Review of Systems
  • This is more targeted to mental health measures and experiences
• Physical Review of Systems
  • Always remember that you are treating the patient – not the chart
  • Be observant, ask them how they feel, explore any possible symptomology

Recognize the Charting Rules Have Changed for Some Payer Sources

So – there used to be these clearly defined boxes of CC and HPI, ROS and Exam, then Plan. And many EMRs are set up that way still.

But it is now the comprehensive data from all the pieces that support a medical decision making model in the final plan for the client that either does or does not make the grade and pass the measure to be paid.

This is relatively new and the nuances are being worked out.

Ratings and EBP Scales Help You Write a Great Psych Note as a NP

Remember your nursing school care plan notes? Yeah. They helped you in NP school by training your mind to think whole systems. For more on how nursing school helped you develop your skills to be a great NP, click here. You know what else you had to chart as a nurse: SOAP and OLD CARTS. They can help guide you here too.

• SOAP Notes: Subjective, Objective, Assessment, and Plan
  • Help you keep your charting clear and concise
• OLD CARTS: Onset, Location, Duration, Characterization, Alleviating or Aggravating Factors, Radiation, Temporal Patterns, Severity
  • Help you think about all the areas you should consider for your documentation.

Some Other Great Tips for Writing a Psych Note as a NP:

• Use a client quote for the Chief Complaint
  • Don’t use a diagnosis here
  • Ask what brings the client in to see you and type that in there
• Ask how their current treatment / medication is working and ask them to rate it for you
  • ie: “Long acting injectable medication appears to work for approximately 2.5 weeks, client reports they can “feel it stop working” at that time and experience more labile moods”
  • ie: “Client attends therapy weekly and reports working toward better coping skills to help with anger outbursts. Reports has not had an “explosive” anger episode in 3 months, improved from their last visit on (date) where the interval was 2 weeks.”

Be Specific

• Ask about Depression and rate it on a scale of 1-10 and the number of days the client experiences symptoms
• Ask about Anxiety and rate it on a scale of 1-10 and the number of days client experiences symptoms
  • ie Client reports Depression as a 5/10 6/7 days per week
  • Ask those alleviating and aggravating factor questions
• Already mentioned above ask about, rate and record substance use
• Ask about homicidal ideation, suicidal ideation
  • Use the PHQ-9 or Columbia, or other scale to assess for this
  • Have a plan in place for positive responses that may require safety planning, intervention, crisis placement
  • Evidence has proven that asking about suicide does, in fact, help, not harm the client who may be contemplating
  • If a client is positive for either homicidal or suicidal ideation details are needed
    • Ask who, what, when, where, if there is a plan
    • Ask what they do when they get those thoughts – what makes it better, what makes it worse
    • How long have they had these thoughts?
    • Do they feel as if they are going to act on these thoughts?
    • Ask and document the answers given
• Ask about auditory or visual hallucinations
  • If client is positive for these, ask what they see and hear
  • Ask how it makes them feel, or if it bothers them
  • Realize different people have different baseline experiences
• Ask about any side effects that may be associated with psychotropic medications – be specific and targeted in your questions
• If a client is on a neuroleptic medication, ensure they have a signed neuroleptic consent in their chart and that you have reviewed with them the medication, what to watch out for, and how to report any issues they may have
• If they are on a psychotropic medication that could cause Abnormal Involuntary Movement, conduct an AIMS at the established intervals for your practice (recommend at least every 6 months)

A Note on ADHD

• If this is a visit for ADHD – use an evidence based practice scale to evaluate
  • For kiddos I like to use a scale that also has a component for the teacher and caretaker to report symptoms
  • Realize that sometimes depression in kids can manifest with inattentive symptoms, and be on the look out for that / include that in your differential

Examination

Telehealth and the expansion of its use for all healthcare providers (Physicians, Nurse Practitioners, Physician Assistants) has expanded for some payer sources.

This has helped with access to care for those who may otherwise go without.

During COVID-19 Global Pandemic there has been a “silent” Second Pandemic of Mental Health.

Leveraging technology to give access to care for those who need it the most is an important way clinicians can meet the needs of clients where they are.

This has also impacted how we do examinations.

But – you can do an AIMS remotely (for most elements).

You can assess some tardive dyskinesia, you can assess eye movement and cognition, you can assess several different things.

And technology is advancing and evolving to where digital stethoscopes can be used for distance visits and some other new “toys” that will aid in doing an exam.

The basic principals of your exam remain the same for psych either in a face to face encounter or via telemedicine.

Use Helpful Templates

Use a “cheat sheet” if you need too at the first – aka a template.

Know what you need to ask, assess, examine.

Have a list of what you need before you see the client – it is always a good idea to check to see if there are pieces missing or that need updated (EBP rating tools, vitals, labs, AIMS, Neuroleptic Consent Forms, etc.).

Go into the visit with a plan and be prepared.

If it is a NEW patient – know how to ask questions and review data to guide your differentials.

If it is an ESTABLISHED patient, do the same thing as you seek to refine the treatment and enhance the outcomes for the client.

What to Write in the Plan for a Great Psych Note as a NP

For the love do not write “continue meds as prescribed” and sign off. If you have an EMR that allows you to not have to free type all. the. things. you are blessed and highly favored! Some of us aren’t that lucky so shhhhh.

Remember the Medical Decision Making Model that is now the basis of payment? Those payer sources want to know that you considered the individual condition of the individual client and that you made an individual plan.

List medications by name. Say what you are prescribing them for and at what dose / instructions.

• If you are going to STOP a medication: Write why
  • “(name of medication) discontinued d/t patient report of (negative side effect or lack of efficacy)

• If you are CHANGING A DOSE of medication: Write what it is, what it is being scribed for, and why the change
  • Increasing Abilify to 5 mg po qd for increased MDD symptoms

Concordance of Care

Informed decision making is important. Collaborating on a plan of care with your patient is important. Educating on the risk and benefits, side effects and laboratory monitoring needs of a medication is important.

And so. is. documenting. that. you. did. these. things!!! Put it in the chart.

Return to Clinic, Therapy Recommendations, Wellness Approaches

Always let your client know when they need to come back and see you – and put that in the plan.

Let your client know about any side effects or things they should watch for with any medication. And put that in the chart.

Counsel of birth control needs for certain medications, if prescribed, have a conversation about this. And document it.

Client a smoker? Connect with cessation products. Put that in the chart.

Referring to the nutrition department? Does the client need labs to monitor for metabolic conditions or drug levels? Did you talk about sleep hygiene or recommend therapy sessions? The plan is a great place to document that information.

The theme: Document. Put it in the chart.

When you write a great psych note as a NP, your aim should be for someone to be able to come behind you, read your note and know what is going on with the patient and why.

For more tips on how to enhance your experience as a NP, follow My Nurse Life Balance on Pinterest.