Every note format behavioral health practices use.

A psychiatric SOAP note has to carry an MSE, a risk assessment, and a polypharmacy plan with monitoring. Generic templates fold that into one assessment paragraph. Auditors notice. So does the next clinician on the chart.

Default for psychiatrists, NPs, and PAs on med-management visits. Affect and thought process have their own labels. Suicidality and homicidality are structured fields. Medication changes track reason, dose, and follow-up parameter.

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:

AriaMD routes as it hears the visit. Patient-reported mood lands in mood. Observed affect lands in affect. Suicidal ideation lands in the risk field with the patient’s framing, not paraphrased into the HPI. Medication changes keep reason and monitoring parameter. You sign the note and own the diagnosis.

A useful DAP note needs more than three boxes. Name the intervention, record the observed response, and name the treatment plan goal it advanced. Record each detail instead of only a recap.

Ships for therapists and counselors. Sized for a 45 to 60 minute visit and CPT 90834 or 90837. Fields hold modality, intervention, response, and next-session plan.

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:

AriaMD routes the named intervention, the observed response, and verbatim statements that carry clinical weight. AriaMD matches the treatment plan goal to the work you did. You own the assessment and the plan.

Agencies, CMHCs, and supervised LCSW or LMFT settings usually require BIRP. The difference from DAP is observation. Behavior is what you saw and heard in the room, not what the client described later. The intervention is a named technique. The response is observed. The plan is concrete and tied to the treatment plan.

Built for agency and pre-licensure practice, including individual, group, and family work. A recap will not survive a Medicaid audit.

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

AriaMD tags observation vs self-report. What the client said about the week lands under reported symptoms. What you saw lands under observed presentation. Named techniques and observed affect or skill change go in intervention and response. Supervisor name carries through for pre-licensure charts.

Sixty minutes of conversation has to become a chart another clinician, a payer, and a future you can act on. A four-paragraph summary is a recap, not an intake.

Ships for psychiatrists, psychiatric NPs, and PAs. Covers chief complaint and HPI, psychiatric history including hospitalizations and prior med trials, family and social history, substance use, MSE, formal risk, differential with reasoning, and a treatment plan with monitoring. Sized for 45 to 60 minutes and 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:

AriaMD routes as it hears the intake. MSE lands in MSE. Risk lands in risk with the patient’s framing. A passing mention of a prior med trial keeps dose, duration, and reason discontinued. Direct quotes stay in the chief complaint when a paraphrase would lose meaning. You review, edit, and sign.

Every Spravato session needs pre and post vitals, a documented two-hour observation, dissociation and sedation assessment, discharge vitals, and a transportation plan. Generic SOAP misses that. Practices end up with a paper checklist and a second entry in the EHR.

Ships for Spravato-certified clinics. Works for 56 mg and 84 mg, induction and maintenance. Pre-dose vitals, dose, observation-interval vitals, CADSS-style dissociation screening, sedation, and discharge criteria each have their own 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:

AriaMD captures the session as it runs. Pre-dose vitals, dose, and observation-interval vitals land in their own fields. Dissociation and sedation are tagged at the timestamps they occurred. Discharge language matches a REMS audit. The Spravato tag keeps the visit on the course view.

A typical TMS induction is 30 to 36 sessions over six to nine weeks. Every session needs treatment parameters, side effects, and a response trend. Payers reauthorize across the course. First-and-last-visit charts fail medical-necessity review.

Built for TMS-certified practices on FDA-cleared protocols: high-frequency left DLPFC for MDD, deep TMS for MDD or OCD, theta-burst, and accelerated. Covers the mapping visit, each treatment session, and scale checkpoints (PHQ-9 every five sessions is common). Sized for a 20 to 40 minute visit 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:

AriaMD captures the parameters the operator dictates, the interval review, and during-session events. Motor threshold and intensity carry across sessions. PHQ-9 or HAM-D scores tag checkpoints and feed the course-response trend. The Active TMS tag keeps a multi-patient course panel filterable.

Buprenorphine induction, methadone clinic, and naltrexone follow-up each have their own shape. All three need more than SOAP: counseling referral, UDS, withdrawal scoring at induction, and the adherence narrative that supports continued prescribing.

Built for addiction-medicine practices and psychiatrists who still document to that discipline after the X-waiver sunset. Covers buprenorphine induction and maintenance, oral naltrexone and Vivitrol, and methadone follow-up. COWS or CINA, UDS, counseling coordination, and DEA-facing controlled-substance fields are in the note, not a lab tab.

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:

AriaMD routes MAT data during the visit. COWS lands in the COWS field. UDS results tag to the visit and the trend. PDMP query confirmation is logged. Buprenorphine and naltrexone variants each pull their own field set. Regulatory paperwork stays in the same chart.

Long-term lithium needs more than a generic med-management note. Serum levels trend. Creatinine, eGFR, and TSH need periodic review. Tremor, polyuria, weight, and cognitive blunting shift visit to visit. The dose decision is the trend, not a single number.

Built for psychiatrists and psychiatric NPs following bipolar patients on lithium. Level history, lab interval, and side-effect trajectory have their own fields. Fits a 20-minute stable check and a longer visit when a level is out of range. The Lithium tag keeps the panel filterable for 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:

AriaMD pulls lithium, renal, and thyroid trends into the note so the dose decision references the trend. Side-effect language stays in its field. NSAID starts, new ACE inhibitors, and low-sodium diets get flagged when they come up. The Lithium tag keeps the panel filterable for quarterly lab-cycle review.

The session is one event. The chart obligation is per member. A 90-minute DBT skills group with eight people is eight notes. Copy-pasting the group focus and handwriting participation is what an audit picks at.

The format supports LCSW and LPC groups. The shared block records focus, intervention, and group dynamics. The member block records participation, response, treatment plan progress, and risk. Each chart gets a complete note.

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

AriaMD captures the group as one event and splits documentation across each participant’s chart. The shared block writes once. Speaker identification attributes participation, disclosures, and skill demonstration to the right member. Supervisor co-sign routes through the supervisor field. CPT 90853 is suggested by default. You sign each member note.

A stable 15-minute video check-in is not a 60-minute intake. A full SOAP on a brief visit inflates the note and can mismatch the billed level of service.

The format supports low-acuity telehealth in psychiatry, therapy, and primary care behavioral health. It supports video and audio-only visits where state law allows. The format holds POS, modifier, and location fields that telehealth audits review. Common codes include 99213 and 99214 with modifier 95, 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:

AriaMD keeps the note brief. Patient location, provider location, and telehealth consent have their own fields. Mood and affect are captured as observed on video, with a note that no physical exam was performed. E-prescribing details flow into the plan. The visit still files on the longitudinal chart.