I’m a psychiatrist drowning in med check notes - AI tools that actually work?
Question by a member of our Twofold community
“I’m a psychiatrist in outpatient care (mix of 99213/99214 med checks, occasional 90833 add‑on). I’m seeing ~18–24 patients a day; notes spill into evenings and weekends. I need concise, compliant med‑management notes that cover MSE, med reconciliation, side‑effects, risk, and medical necessity—without copy‑paste clichés. HIPAA is non‑negotiable; I also need PDMP checks, labs, and refill rationale captured. Which AI tools actually reduce charting time without blowing up my workflow or audit risk?”
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
- Before (30–60s): Load last plan, active meds, labs due.
- During: Dictate a 20–40s “interval update” (symptoms, function, adherence, side-effects).
- After (2–3 min): Generate draft → verify MSE & necessity → confirm plan → sign.
Core sections (audit-friendly)
Section | Auditors expect | 1-line cue |
|---|---|---|
Interval change | Why today; what’s new | “Since last: mood/sleep/function/adherence/SEs.” |
Meds & recon | Current list; adherence; changes | “Takes as rx’d? Missed? SEs? OTC/supps?” |
MSE | Specific descriptors | “Speech/mood/affect/thoughts/SI/HI/insight.” |
Risk | SI/HI; protective factors; access | “Denies SI/HI; no access; PF: family/work.” |
PDMP/Labs | Checked/ordered when relevant | “PDMP clean; A1c/lipids ordered.” |
Necessity | Symptoms → impairment → need | “Work impairment from anxiety → med adj.” |
Plan/Consent | Dose/titration; R/B/A; FU | “Sertraline 50→75; R/B/A discussed; FU 4w.” |
Tool fit (pick one)
Tool | Best for | Watch-outs |
|---|---|---|
Ambient scribe | Hands-free capture | BAA; mute sensitive bits; trim verbosity |
Dictation → AI | Fast end-of-visit | Needs your structured prompt |
Template-aware AI | Consistent note blocks | Rotate phrasing; avoid clones |
EHR macros + AI | Lowest friction | Map fields to E/M support |
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.
What Clinicians Are Saying on Reddit and Forums About Note Backlogs
How Twofold can help: Twofold’s psychiatrist-ready templates mirror your med-check cadence (Interval → Meds → MSE → Risk → Plan) and surface prompted fields for PDMP/labs, side-effect tracking, and decision rationale. Ambient capture or quick dictation turns high-signal snippets into a clean draft that fits 99213/99214 notes, with HIPAA compliance and BAA available.
Comments
2 commentsAll comments are reviewed by our moderators. Only comments that contribute meaningfully to the conversation will be approved and published.
MaryAnn J.
PMHP
What do you do on days when two or three complex patients blow up the schedule, do you accept a few leftover notes?
Donna Pharow
Practice Owner
What would you consider ‘too minimal’ for a catch-up note if insurance ever audits?
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