Frequently Asked Questions:
Initial Psychiatric Evaluation
What are common documentation mistakes in psychiatric evaluations?
Psychiatric evaluations are foundational to diagnosis, treatment planning, and reimbursement—but even experienced clinicians can fall into common documentation pitfalls. These mistakes can lead to inaccurate diagnoses, compliance issues, denied claims, or even legal risk. Below are some of the most frequent errors, along with practical examples and tips to avoid them.
1. Vague or Non-Specific Language
Mistake: Using generalized terms like “patient appears anxious” or “mood normal” without supporting observations.
Example:
“The patient is anxious.”
→ This lacks clarity. What behaviors or signs support this conclusion?
Better:
“The patient was visibly trembling, avoided eye contact, and reported racing thoughts—consistent with anxiety.”
Tip: Use observable, measurable behaviors to support clinical impressions, especially in the mental status exam (MSE).
Mistake: Jumping straight into symptoms without establishing a narrative or timeline.
Example:
“Patient reports depression.”
→ No context is given on onset, triggers, or duration.
Better:
“Patient reports persistent low mood, fatigue, and hopelessness for the past 4 months following a divorce.”
Tip: The HPI should answer what, when, how long, and why now—not just what’s wrong.
3. Incomplete Risk Assessments
Mistake: Failing to assess or document suicide risk, self-harm, or harm to others—especially when warning signs are present.
Example:
“Patient is stable.”
→ This skips over crucial safety details.
Better:
“Patient denied suicidal ideation, intent, or plan. No history of self-harm. No homicidal thoughts or access to weapons.”
Tip: Always document both presence and absence of risk factors to ensure defensible care.
4. Copy-Paste or Template Overuse Without Customization
Mistake: Relying too heavily on templates without tailoring content to the specific encounter.
Example:
A note stating “patient is calm and cooperative” appears in every session—even on days when the patient was agitated.
Better:
Templates should be starting points, not copy-paste scripts. Always edit to reflect the patient’s current presentation.
5. Missing Functional Impact or Medical Necessity Language
Mistake: Documenting symptoms without connecting them to how the patient’s functioning is impaired.
Example:
“Patient has PTSD.”
→ This won’t support insurance reimbursement on its own.
Better:
“PTSD symptoms, including nightmares and hypervigilance, are significantly impairing patient’s ability to maintain employment and relationships.”
Tip: Include evidence that shows why treatment is clinically necessary—this is essential for audits and utilization reviews.
Struggling to find the right words?
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6. Failure to Note Collateral Information or Third-Party Input
Mistake: Overlooking information from family members, caregivers, or other professionals when relevant.
Example:
Patient with memory issues is evaluated without mentioning input from spouse or prior providers.
Tip: When collateral data is gathered, document how it informed your clinical impression (with appropriate consent).
7. Lack of Diagnostic Justification
Mistake: Listing a diagnosis without explaining how it was determined.
Example:
“Diagnosis: Major Depressive Disorder.”
→ No criteria or rationale is provided.
Better:
“Patient meets DSM-5 criteria for Major Depressive Disorder with symptoms including persistent low mood, loss of interest in activities, and insomnia for >2 weeks.”
Final Thought:
Good psychiatric documentation isn’t just about thoroughness—it’s about clinical reasoning, clarity, and defensibility. Structured templates can help, but must be paired with clinician insight and individualized content.
ICANotes makes it easier to avoid common documentation mistakes by providing clinically structured templates that prompt for essential components like the mental status exam, risk assessments, diagnostic justification, and medical necessity language. Built-in safeguards discourage copy-paste errors by auto-updating time-sensitive fields and encouraging session-specific input. For telehealth, collateral input, and specialty evaluations, ICANotes includes customizable sections that guide clinicians to capture the right details—ensuring documentation is both compliant and clinically meaningful.
With ICANotes, behavioral health professionals can streamline evaluations without sacrificing quality or audit-readiness.
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