OP Note Editor

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What Patient Reports (Your Summary)

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PHQ-9 Score

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Consistent Matches history Evolving Severity/specifier change Changing Updating diagnosis

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P - Plan

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Additional Plan Notes (optional)

Follow-Up

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S - Subjective

Last Visit Type

Arrival Time

What We Explored / Discussed

Themes

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My Observations

Safety Screening

Medications

Medication Adherence

Side Effects

Medication Changes/Concerns

O - Objective

PHQ-9 Score

GAD-7 Score

Other Objective Data (leave blank if none)

A - Assessment

Psychiatric History

Current Presentation

Consistent Matches history Evolving Severity/specifier change Changing Updating diagnosis

Clinical Status

Clinical Reasoning / Formulation

Risk Factors

Protective Factors

Overall Acute Risk

P - Plan

Medication Status

Full Plan

Total Time Spent

Follow-Up

Full SOAP Note (with MSE)

S - Subjective ▼

Last Visit Type

Visit Type

Arrival

Total Time Spent

Chief Complaint / What Patient Reports

Activities

Sleep

Therapy

Medication Adherence

Side Effects

Other Updates

My Observations

Safety Screening

O - Objective (Mental Status Exam) ▼

Appearance

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Affect

Thought Process

Thought Content

Perceptions

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Insight / Judgment

Measures

PHQ-9 Score

GAD-7 Score

A - Assessment ▼

Psychiatric History

Current Presentation

Consistent Matches history Evolving Severity/specifier change Changing Updating diagnosis

Clinical Reasoning / Formulation

Clinical Status

Clinical Status Details

Risk Factors

Protective Factors

Overall Acute Risk

P - Plan ▼

Labs

Current Medication Regimen

Medication Changes

Medication Strategies Discussed

Therapy/Psychotherapy Plan

Follow-Up

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