How do you document psychiatric medication changes and rationale without 20-minute charting?

Brief Answer

Use a five part micro note that you can populate in two to four minutes. Anchor the change to today’s symptoms and function, state the exact change and why now, list alternatives considered, capture risk and monitoring, and set a clear follow up. Keep a small phrase bank for common scenarios so you personalize in seconds rather than write from scratch.

The Longer Answer

1) The five part micro note for medication changes

Fill in short lines, then sign.

1. Clinical status today
   Symptoms, function, interval change, adherence, side effects.
2. Decision
   Start, continue, increase, decrease, switch, add adjunct. Specify dose and schedule.
3. Rationale and alternatives
   Why this choice today, alternatives considered and why not chosen.
4. Risk, consent, and monitoring
   Safety risks discussed, PDMP or labs if relevant, vitals, pregnancy status if applicable, counseling points.
5. Follow up and return precautions
   Time window, what to call for early, coordination with therapy or primary care.

2) One minute dictation script you can reuse

“Since last visit, symptoms and function are [summary]. Adherence [ ], side effects [ ]. Today I will [medication action, dose, schedule] because [target symptoms or treatment goal]. Considered [alternative], not chosen due to [reason]. Discussed risks and benefits including [top two], patient agrees. Monitoring will include [labs or vitals or PDMP], and education provided. Follow up in [timeframe], return sooner for [red flags].”

3) Decision matrix for common med actions

4) Phrase bank to speed rationale and consent

Use, then personalize with one or two specifics.

• Rationale
  “Change is indicated due to persistent [symptom] affecting [function].”
  “Prior trial at [dose] for [duration] produced partial response. Dose increase targets residual [symptom].”
  “Switch chosen after inadequate response and patient preference to avoid [side effect].”
• Alternatives considered
  “Considered [alt med or psychotherapy], not chosen due to [interaction, prior failure, access, preference].”
• Risk and consent
  “Discussed common and serious risks, benefits, and alternatives. Patient states understanding and agrees to plan.”
  “Reviewed black box warnings and safety plan. Protective factors include [ ].”
• Monitoring
  “PDMP reviewed, no concerning fills.”
  “Ordered [labs] with plan to review results and adjust as needed.”
  “Advised to monitor BP, pulse, weight, and sleep.”
• Follow up
  “Follow up in 4 weeks for response and tolerability, sooner if adverse effects or mood worsening.”

5) Minimum content that supports E M and audit readiness

6) Compliance guardrails that keep notes short and safe

• Anchor justification to today’s specifics to avoid cloned language.
• Record PDMP, labs, vitals, or pregnancy testing when applicable.
• Label late entries if used, keep your edit as the final author step.
• For 90833, briefly document psychotherapy content and time if performed.