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Compliance and documentation

A helpful documentation checklist for prescribers

Here are the documentation and notes requirements you’ll want to remember as a prescriber.

As a prescriber, you have a lot of responsibilities on top of providing mental health care to your patients. Administrative duties like documentation are also an important part of your job — and one way you can better support patients on their mental health journeys. “Thorough, precise documentation is essential for ensuring patient safety, continuity of care, and compliance with payer standards,” says Jessica Belvin, CPC, CPMA, and Headway’s medical coding specialist.

The problem? When you’re working with multiple patients, it can be hard to keep track of everything you need to document for each one. A checklist, Belvin says, can help you remember key details efficiently, reduce documentation errors, and most importantly, provide consistent, quality care in therapy. 

Keep reading to learn more about what you should include in your documentation as a prescriber.

Prescriber documentation essentials

Remember: Your documentation may be audited at some point, so the easier it is to read and locate key information, the better. Following these guidelines will help ensure clarity, accuracy, and compliance.

General documentation requirements

These general guidelines apply to all documentation for prescribers, such as psychiatrists and nurse practitioners.


  • Ensure CPT & ICD-10 codes listed in the documentation match those billed.
  • The Date of Service (DOS) in the note should match the DOS billed.
  • Include the Patient’s full name and DOB on every page.
  • Make sure the chief complaint or reason for encounter is clearly documented (e.g., “follow-up” alone is insufficient—specify symptoms or problems being followed up on).
  • Provider Signature: Include “Electronically Signed by: [Name/Credentials/Date signed]” and ensure the note is signed within 72 hours of the date of service.
  • Documentation should be unique to the patient and date of service with person-centered details (e.g., behavior descriptions, quotes). Avoid cloning or copy/paste.
  • New patients: Include history for best practice (not required but improves quality of care), such as:

Prior mental health treatment

Prior medical treatment/current conditions

Psychosocial information

Psychotherapy and E/M documentation

Whether you’re providing therapy or E/M services, these documentation guidelines are essential for getting reimbursed by the insurance payer. 


  • Separate add-on psychotherapy documentation from E/M sections (best practice: place it at the bottom of the note, before your signature).
  • Add-on psychotherapy time should be distinct from E/M time, with start and stop times documented. For example:

Appointment duration: 12:00 pm - 12:45 pm

Psychotherapy time: 12:20 pm - 12:45 pm

  • If billing for 90785 (Interactive Complexity), specify the barrier to communication, service delivery details, or any sentinel events, including whom it was reported to.
  • Do not simply document the criteria, as this is insufficient support.

Medication management 

As a prescriber, the additional responsibility of managing medication requires extra documentation steps. Keep these in mind during appointments when you are dealing with a client’s medication. 


  • Clearly document medications managed by another provider versus those you are managing. Include the name, dosage, and frequency for each medication at least once in the note.
  • If no medications are prescribed, document “No medications prescribed.”
  • If recommending medications and the patient refuses, document the recommendation, reason, and the patient’s refusal (this is considered medication management).
  • For any prescribed/monitored medications, document counseling on risks and the importance of adherence.
  • If a controlled substance is prescribed, document that the PDMP was checked as per state mandate.

Time-based documentation 

You may decide to bill by time rather than medical decision-making. When this is the case, ensure start and stop times are recorded. Any time-based code requires start and stop times.

Risk and assessment 

Your assessment of a patient’s risk level can inform your level of medical decision-making, so be sure to follow these guidelines in your documentation.


  • Symptoms should be consistent with the primary/secondary diagnosis codes.
  • Include a risk assessment (e.g., SI and HI risk, overall risk level such as low, moderate, high). If moderate or high risk, include a safety plan in the note.
  • Documentation should indicate whether the patient’s symptoms are improving, not improving, or maintaining. If not improving, document the barriers to treatment progress.

Treatment plan 

Outline a recommended course of treatment/treatment plan, including details on medications (starting, stopping, continuing), referrals, return schedule, and next appointment date.

Telehealth documentation 

If you provide services via telehealth, you’ll need to include a few extra pieces of information in your documentation. 


  • Include a telehealth attestation statement: “Services were provided via synchronous audio/video telehealth on a HIPAA-compliant platform. The provider was located in their office, and the patient was located at [Home/Other location (address if available)]. The patient consented to telehealth services, and all standards of care were maintained.”
  • Ensure the Place of Service (POS) billed matches what is documented in the note (telehealth or in-office).

Mental status and allergies 

Finally, you should always properly document your patient’s mental state and any allergies that may affect their prescriptions or overall health.


  • Document a full mental status exam.
  • Document any allergies (medication, environmental, food, etc.), or state “No Known Allergies (NKA)” if none are reported.

How to improve psychatric therapy documentation

Keeping these points in mind can help make your therapy documentation more effective and efficient.

Include essential details. 

Specificity is key with documentation — it’s your job to show the payer why they should pay you for a particular code. Thorough documentation reduces the risk of unnecessary audits and clawbacks. 

Provide rationale.

To that end, you should also explain in every note why the specific treatment was appropriate for your patient’s symptoms and presentation during a session. 

Be concise. 

While documentation should be precise, it should also be easy to read, whether you or a payer is reviewing the notes. 

Skip jargon. 

Clarity is essential in all your documentation. Avoid abbreviations or jargon that may be difficult for payers or other healthcare providers to understand. 

Highlight patient progress.

In all documentation, show your patient’s progress, including both setbacks and struggles and growth or improvements.

Helpful resources

Example note

Want to see how all of these components play out in a note? Here’s an example of a note for codes 99214 + 90836 (E/M with Psychotherapy).

Patient Name: Sallie Mae

Date of Service: 04/16/2023

Patient DOB: 06/29/1945

Appointment Time: 11:00am-12:00pm


The total time I spent caring for this patient today was 75 minutes which included: interviewing the client, documenting, reviewing the patient's responses to questionnaires, discussing treatment plans, coordinating care, prescription management and counseling the client on managing her mental health.

Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345. Provider was located at their office: 456 Storybook Ln Hollywood CA 96852

This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.

Subjective

Chief Complaint: Follow-up consultation for a 77-year-old female, presenting with exacerbation of symptoms related to her chronic mental health conditions.

History of Present Illness: Sallie reports a recent escalation in symptoms associated with both depression and post-traumatic stress disorder (PTSD). She describes increased feelings of sadness, hopelessness, and intrusive thoughts related to traumatic experiences. Sleep disturbances, including nightmares and insomnia, have intensified, impacting his overall functioning and ability to maintain daily routines. Sallie acknowledges heightened irritability and difficulty concentrating at work, further exacerbating her distress

Psychosocial History: Married, 2 children at home, works in office, college graduate, parent good relationship

Behavioral Health/Psychiatric History: therapy previously, no hospitalizations 

Medical History: High BP, knee surgery

Current Medications: prazosin 1 mg at bedtime, sertraline 100 mg 1xday

Allergies: NKA

Objective:

Exam: Vital signs stable. Patient displays signs of psychomotor agitation and hyperarousal. Mood observed as consistently low, with increased anxiety evident during the examination.

ROS: 

  • Constitutional: denies unexplained weight loss or weight gain, fever, night sweats 
  • HEENT: denies
  • Cardiovascular: denies
  • Respiratory: denies 
  • Neurological: denies 
  • Psychiatric: depression 
  • Gastro: denies 
  • Musculoskeletal: denies

Tests: The patient's score on PHQ-9 was 9 suggestive of mild depression. The patient's score on GAD-7 was 7 suggestive of mild anxiety.

MSE: Orientation: Alert & Orientedx3

  • Appearance: neatly dressed, appears stated age
  • Speech: Normal
  • Perception: Normal
  • Thought content: logical
  • Insight/judgment: Normal
  • Cognition: Normal

Substance Abuse Assessment: 2-3 drinks alcohol/month, nonsmoker, no recreational drug use 

Risk Assessment: No SI/HI, overall risk is moderate. Safety plan has been established.

Assessment:

F41.1 Generalized Anxiety Disorder:

Sallie presents with recurrent episodes of major depressive disorder, currently experiencing an exacerbation. Her symptoms meet the DSM-5 criteria for Major Depressive Disorder, as follows: 

  • Depressed Mood: Increased feelings of sadness and hopelessness.
  • Anhedonia: Diminished interest or pleasure in activities.
  • Sleep Disturbances: Insomnia.
  • Psychomotor Changes: No specific details provided.
  • Fatigue or Loss of Energy: Impact on overall functioning and daily routines.
  • Feelings of Worthlessness or Excessive Guilt: Not explicitly stated, but feelings of hopelessness
  • imply negative self-perception.
  • Diminished Ability to Think or Concentrate: Difficulty concentrating at work.


F43.12 Post-traumatic stress disorder, chronic, exacerbated by recent stressors:

Sallie has a chronic history of post-traumatic stress disorder, now exacerbated by recent stressors. Her symptoms meet the DSM-5 criteria for PTSD, as follows:

  • Intrusion Symptoms: Intrusive thoughts related to traumatic experiences and nightmares.
  • Avoidance: Not explicitly mentioned, but can be inferred from difficulty concentrating and
  • heightened distress.
  • Negative Alterations in Cognition and Mood: Increased feelings of sadness, hopelessness, and
  • irritability.
  • Alterations in Arousal and Reactivity: Heightened irritability, difficulty concentrating, and insomnia.

Plan:

1. Adjustment Of Medication Regimen:

  • Increase dosage of sertraline from 100 mg to 150 mg daily for enhanced management of depressive symptoms.
  • Initiate low-dose prazosin (1 mg at bedtime) to target PTSD-related nightmares and improve sleep quality.


2. Referral for intensive psychotherapy:

Implement weekly sessions of prolonged exposure therapy (PET) to address PTSD symptoms and facilitate emotional processing of traumatic experiences.


3. Safety monitoring: Personalized safety plan was developed to address potential suicidal ideation or self-harm behaviors.


4. Follow-up and next steps:

  • Schedule bi-weekly follow-up appointments to monitor response to treatment, adjust medication as necessary, and evaluate progress in psychotherapy.
  • Collaborate with patient to establish a social goal: Sallie will endeavor to engage in at least one social activity per week to foster social support and reduce feelings of isolation.
  • Sallie has been advised to adhere to her medication regimen and of the risks/side effects
  • of the medications. Sallie will call the office during office hours to report side effects. In case of emergency, please go to your nearest Emergency Room or call 911/988.


Psychotherapy: 11:18am - 12:00pm   

Behavior(s) addressed: sadness, hopelessness, and intrusive thoughts related to traumatic experiences

Interventions used: supportive therapy and utilized CBT techniques to reframe cognitive distortions 

Response: Fair, minor reduction in sadness and intrusive thoughts

Goal/Plan: Sallie will decrease frequency and intensity of intrusive thoughts and episodes of sadness by utilizing coping strategies, referral to PET therapist for more in-depth work on trauma-related issues. Sallie is progressing well. 


Electronically signed by,

Jane Smith, PMHNP-BC 4/17/2023

______________________________________________________________________________________________ 

Rationale information is not required in your note; it is provided for educational purposes only.    

Rationale and How the CPT Codes Were Selected:

Number and Complexity of Problems Addressed: 2 Chronic illnesses with exacerbation 

Data Reviewed/Analyzed: PHQ-9, GAD-7

Risk: Moderate: Prescription drug management

Rationale: The client displays High number & complexity of problems with two chronic illnesses with exacerbation, Low amount of data reviewed, and Moderate risk for prescription management. A total of 42 minutes of psychotherapy was provided during the session.

Level of MDM: Moderate

CPT Codes Selected: 99214 + 90836

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