I’m a psychiatrist drowning in med check notes - AI tools that actually work?

Brief Answer

Yes ‑ AI can help if it’s tuned for brief psychiatric E/M. Use a HIPAA‑eligible scribe with structured prompts (chief concern → interval change → MSE → med plan with risks/benefits → follow‑up). Capture decision‑making (why this med/dose/monitoring now), document safety/risk, and tie symptoms to function. Keep a tight template, feed the scribe high‑signal snippets during/after the visit, and always finalize with your own edits. You’ll cut note time to minutes while strengthening audit‑ready documentation.

The Longer Answer

What matters in a 15-min med check

• Medical necessity: Tie today’s visit to symptoms + functional impact.
• Decision-making: Why this med/dose now; alternatives; monitoring.
• Risk/safety: SI/HI, adverse effects, PDMP (when relevant).
• MSE: Specific, not boilerplate.
• Plan & follow-up: Dose/titration, R/B/A discussed, monitoring, return.

Quick workflow

1. Before (30–60s): Load last plan, active meds, labs due.
2. During: Dictate a 20–40s “interval update” (symptoms, function, adherence, side-effects).
3. After (2–3 min): Generate draft → verify MSE & necessity → confirm plan → sign.

Core sections (audit-friendly)

Tool fit (pick one)

Prompts that work

• Interval: “Med check for [dx]. Since last: mood/sleep/function/adherence/SEs/stressors.”
• Decision: “Because [symptoms/impairment], will [start/increase/continue] [med]; alternatives [x]; monitoring [labs/vitals].”
• Risk/Consent/FU: “SI/HI [ ], PF [ ]; R/B/A discussed; return [timeframe].”

Compliance & coding (essentials)

• HIPAA/BAA, human review, no cloned text.
• Document PDMP/labs when applicable; label late entries.
• 99213 vs 99214: support with MDM or time; add 90833 only if psychotherapy content/time present.

Minimal reusable template

CC/Interval → Med Reconciliation → MSE → Risk → Data/Monitoring (PDMP/labs) → Assessment/Medical Necessity → Plan/Consent → Follow‑up.