A mental health follow-up note template that sets out what belongs in each section, ready to adapt to your own clinic.
01Follow-up note
TemplateMental health
Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]
Mental health follow-up note
1Since the last visit
What has changed since the last visit, in the patient's words.
Results received since the last visit, and whether they were discussed.
2Examination
Mental state examination, covering appearance, behaviour, speech, mood, thought, perception and insight.
3Review
Risk assessment, covering risk to self and others, with protective factors.
The working formulation.
4Plan
Treatment options discussed and agreed.
Crisis plan, with contacts the patient can use out of hours.
5Next review
Crisis contacts given, and when to use them.
When the next review is due.
How the Wai scribe fills it
The same note, written from an invented consultation.
Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.
01Follow-up note
SignedAI-assisted, edited by the clinician
Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person
Mental health follow-up note
1Since the last visit
Two therapy sessions attended. Sleep improving.00:35
2Examination
Appropriately dressed, good rapport. Mood described as low, affect reactive. No perceptual disturbance. Good insight.07:10
3Review
Denies thoughts of self-harm. Protective factors include family and work. Risk assessed as low.09:20
4Plan
Referral for talking therapy. Review in four weeks.10:30
5Next review
Crisis contacts given verbally and in writing.11:15
Questions
What goes in a mental health follow-up note?
Since the last visit, Examination, Review, Plan and Next review. Each section on this page lists what belongs in it, written for mental health.
Is the worked example a real patient?
No. The consultation is invented for this page, and no real patient or record is used.
Does the scribe sign the note?
No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.
Can we use our own note structure?
Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.
