Psychiatric evaluation templates with an AI first draft
Interview the patient as you normally would. My Clinical Writer organizes the interview into a structured psychiatric evaluation, from chief complaint and history to mental status exam, risk assessment and recommendations, for you to review and complete.
Free trial, no credit card required.
From interview to evaluation
A comprehensive psychiatric evaluation can take longer to write than to conduct. My Clinical Writer handles the structure and the first draft so your time goes into the clinical reasoning. It is designed for psychiatrists, psychiatric nurse practitioners, clinical psychologists who conduct evaluations, psychiatric residents and fellows, and licensed mental health professionals in integrated care settings.
With voice recording
Record the evaluation and cover the usual ground: chief complaint, history of present illness, psychiatric history, mental status and risk factors. The AI transcribes the interview and organizes it into the standard evaluation sections, arranging mental status findings systematically and laying out the risk assessment for you to check.
Typing or dictating
Prefer to write? Enter the patient information, chief complaint and relevant history as brief notes, or upload existing documents. The AI turns your bullet points into professional prose, keeps every section of the template covered and uses appropriate clinical terminology.
Review, refine and export
Edit any section, add or change the diagnostic impression, include your formulation and clinical reasoning, and adjust the treatment recommendations. Then copy the evaluation to your EHR or save it as a Word document, and save your customized structure as a template for next time.
Every section of a comprehensive evaluation
Identifying information
Demographics, presenting problem, referral source and reason for evaluation.
History of present illness
Symptom onset and duration, severity and frequency, functional impairment, previous episodes.
Psychiatric and medical history
Previous diagnoses, treatment history, medications and medical conditions.
Mental status examination
Appearance and behavior, mood and affect, thought process and content, cognition.
Risk assessment
Suicidal and homicidal ideation, safety planning and protective factors.
Diagnostic impression
DSM-5 diagnoses, differential diagnoses, diagnostic reasoning and specifiers.
Treatment recommendations
Medication and therapy recommendations, level of care and follow-up plan.
Additional history
Social, family, substance use and developmental history.
Why use a template at all?
A consistent structure makes evaluations easier to read for the next clinician, easier to audit, and less likely to miss a required element such as a documented risk assessment or the reasoning behind a diagnosis. The template keeps that structure in place while you focus on the content. Because it is fully editable, it can follow DSM-5 terminology and your organization's own conventions at the same time.
For therapy notes after the evaluation, see therapy progress notes. For disability examinations for veterans, see VA disability mental health evaluations.
The AI drafts. You decide.
My Clinical Writer writes a first draft from what you record, type or upload. You review it, edit anything that does not match your clinical judgment, and only then sign or export it. The assessment, the diagnosis and the plan are always yours, and you remain responsible for the final record.
Patient data is protected as described on our security and HIPAA page: 256-bit encryption in transit and at rest, role-based access, audit trails, and a Business Associate Agreement that every account accepts at registration.
Questions, answered.
Can I customize the evaluation template?
Yes. The template is a starting point. You can add, remove or rename sections, save your own versions, and keep variations for different settings, such as child and adolescent, geriatric or substance use evaluations.
Does the AI make the diagnosis?
No. The AI organizes and writes up the information you gathered. The diagnostic impression, formulation and recommendations are your clinical judgment, and you review and edit every section before the evaluation is final.
Will the evaluation meet my payers' documentation requirements?
The template covers the components of a comprehensive psychiatric evaluation, and you can add any section a payer or setting requires. Requirements differ, so check the specific rules of your payers and organization.
How do I get the evaluation into my records system?
Copy the finished evaluation into your EHR or save it as a Word (Docx) document. Your evaluations also stay in your account until you delete them.
Is patient information protected?
My Clinical Writer is HIPAA and PHIPA compliant, with 256-bit encryption in transit and at rest, access controls and audit trails. Every account accepts our Business Associate Agreement at registration. See the security page.
What kinds of evaluations can I write?
Initial diagnostic evaluations, medication management assessments and other psychiatric assessments, as long as a template describes the sections you need. You can start from the standard evaluation template or build your own.
Try it on your next note.
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