Built in Direct Collaboration with Practicing Psychiatry Physicians

Psychiatry Clinical Notes in Seconds

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Built in direct collaboration with practicing psychiatrists, ExamScribe handles the nuanced documentation of psychiatric medicine — complete mental status examinations, risk assessments, medication management rationale, and psychotherapy progress notes. Notes that capture the complexity of psychiatric care without hours of documentation.

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ExamScribe — Psychiatry Encounter
🎤 Your Voice Recording

"32-year-old female with major depressive disorder, here for medication management follow-up. She's been on sertraline 150mg for 4 months. PHQ-9 today is 11, down from 18 at our last visit. She reports improved sleep, better energy, but still has low mood and anhedonia most days. No suicidal ideation, no homicidal ideation. She denies any manic symptoms. Mental status exam: alert, cooperative, appropriate affect, thought process linear and goal-directed, no psychosis. I'm going to increase sertraline to 200mg and add a referral for CBT."

📄 Generated Clinical Note
CHIEF COMPLAINT: Major depressive disorder — medication management follow-up HISTORY OF PRESENT ILLNESS: 32-year-old female with major depressive disorder presenting for medication management follow-up. Currently on sertraline 150mg daily for 4 months. PHQ-9 score 11 today (moderate depression), improved from 18 (moderately severe) at last visit — representing partial response. Patient reports improved sleep quality and energy levels. Persistent low mood and anhedonia most days. Denies manic or hypomanic symptoms. No psychotic symptoms. RISK ASSESSMENT: Suicidal ideation: Denied. No plan, no intent, no recent attempts. Homicidal ideation: Denied. Self-harm: Denied. Risk level: Low — no acute safety concerns. MENTAL STATUS EXAMINATION: Appearance: Well-groomed, appropriate dress. Behavior: Cooperative, good eye contact. Speech: Normal rate, rhythm, and volume. Mood: "Still low but better than before." Affect: Mildly dysthymic, congruent with mood. Thought Process: Linear, logical, goal-directed. Thought Content: No suicidal/homicidal ideation. No delusions. Perceptions: No hallucinations reported or observed. Cognition: Alert and oriented x4. Concentration intact. Insight/Judgment: Good/Good. ASSESSMENT & PLAN: 1. MDD, partial response to sertraline — sertraline increased to 200mg daily 2. CBT referral placed — evidence-based adjunct to pharmacotherapy 3. PHQ-9 monitoring at each visit 4. Return in 4 weeks; sooner if symptoms worsen or safety concerns arise 5. Safety plan reviewed and updated

Built for How Psychiatry Physicians Actually Work

Not a generic scribe with "Psychiatry" added. Every template, every prompt, and every output was purpose-built for psychiatry workflows.

Complete Mental Status Examination

Generates structured MSE documentation covering all required domains — appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, and insight/judgment. The documentation psychiatry billing requires.

Risk Assessment Documentation

Suicidal ideation, homicidal ideation, self-harm, and safety planning are documented with the specificity that protects both your patients and your practice. Risk level, protective factors, and safety plan elements captured in every relevant encounter.

Medication Management Rationale

The "why" behind psychiatric medication decisions is what separates defensible documentation from liability. ExamScribe captures your clinical reasoning — why you chose this medication, why you're adjusting the dose, what you're monitoring for.

Psychiatry-Specific Context Template Builders

AI can hear your words but cannot see your exam. These structured builders push real clinical findings to the AI in one click — eliminating hallucination and ensuring every note reflects what you actually did.

Major Depressive Disorder

PHQ-9 score, symptom review, medication response, side effects, CBT referral, safety assessment

Bipolar Disorder

Current episode, mood chart, medication levels (lithium/valproate), cycling frequency, safety

Anxiety Disorders (GAD/Panic/Social)

GAD-7 score, panic frequency, avoidance behaviors, medication, therapy progress

PTSD

PCL-5 score, trauma history, hyperarousal/avoidance/intrusion symptoms, EMDR/CPT progress

ADHD (Adult)

ADHD-RS score, functional impairment, stimulant response, side effects, diversion risk assessment

Schizophrenia / Psychosis

PANSS items, positive/negative symptoms, antipsychotic response, metabolic monitoring, insight

OCD

Y-BOCS score, obsession/compulsion themes, ERP progress, medication augmentation

Substance Use Disorder

AUDIT/DAST score, substance use history, MOUD (buprenorphine/naltrexone), recovery support

Insomnia

ISI score, sleep hygiene, CBT-I progress, medication management, sleep study indication

Eating Disorders

BMI trend, restriction/purging behaviors, medical stability, level of care assessment

Integrated Compliance Engine

Psychiatric Documentation Has Unique Compliance Requirements. Don't Overlook Them.

Psychiatry faces specific compliance challenges — psychotherapy add-on codes, medication management vs psychotherapy billing, and risk assessment documentation. ExamScribe's compliance engine ensures your notes meet the requirements for the services you're delivering.

Psychotherapy Add-On Code Documentation

When billing psychotherapy add-on codes (90833, 90836, 90838) with E/M, the note must document both the medical decision-making and the psychotherapy time separately. The engine verifies both elements are present.

Risk Assessment Documentation

Inadequate risk assessment documentation is one of the most common sources of psychiatric liability. The engine checks that every encounter with a patient at risk includes documented suicidal/homicidal ideation assessment, risk level, and safety plan.

Medication Management E/M Level Support

Psychiatric medication management visits must document sufficient MDM complexity to support the billed E/M level. The engine verifies your note captures the complexity of psychiatric pharmacotherapy decisions.

Controlled Substance Prescribing Documentation

Stimulants, benzodiazepines, and buprenorphine require documented clinical indication, risk assessment, and monitoring plan. The engine checks that your note contains the elements required for controlled substance prescribing defensibility.

Validated Screening Tool Documentation

PHQ-9, GAD-7, PCL-5, and other validated tools require documented scores and clinical interpretation. The engine verifies scores are present and clinically correlated — not just listed.

Two-Pass AI Compliance Audit

Every note is analyzed for coding accuracy, documentation sufficiency, and payer-specific requirements. You receive a detailed gap report — reviewed and attested by you before any changes are made.

Three Steps. That's It.

Start generating notes in under a minute.

1

Record

Click record and speak naturally about the encounter — during the visit, after the visit, or just key findings. No special commands.

2

Generate

ExamScribe transcribes your recording and generates a complete, properly structured psychiatry note with accurate specialty terminology in seconds.

3

Review & Export

Review the note, make any quick edits, and copy it into your EHR or export as PDF. Done.

Simple, Transparent Pricing

One plan. Everything included. No per-note fees.

Individual Physician
MonthlyAnnual Save $120/yr
$89/mo

billed annually ($1,068/yr)

  • 400 AI credits per month
  • All Psychiatry template builders
  • Compliance audit engine
  • Document analysis & appeal letters
  • Voice-to-note in seconds
  • PDF & Excel export
  • HIPAA compliant — signed BAA included
  • 30-day free trial
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Your Patients' Data Is Sacred

Built with the same standard of care you bring to your patients.

HIPAA Compliant

  • Signed Business Associate Agreement
  • AES-256 encryption at rest
  • TLS 1.2+ in transit
  • SOC 2 Type II Azure data centers (US only)

Zero Data Sharing

  • Transcripts never used to train AI
  • No third-party data sharing — ever
  • Data never leaves US servers
  • You own your data — delete anytime

Automatic Protection

  • No audio recordings stored
  • Auto-delete on your schedule
  • Complete audit logging
  • Session timeouts enforced

Frequently Asked Questions

Does ExamScribe handle the sensitive nature of psychiatric documentation?

Yes. ExamScribe is designed with psychiatric documentation in mind — capturing clinical information accurately while maintaining the professional tone appropriate for mental health records. PHI is handled with the same HIPAA protections as all other specialties.

Can ExamScribe document both medication management and psychotherapy in the same note?

Yes. When billing psychotherapy add-on codes with E/M, ExamScribe documents both the medical decision-making and the psychotherapy content separately — meeting the documentation requirements for combined billing.

How does ExamScribe handle risk assessment documentation?

The risk assessment is built into every relevant psychiatric template. ExamScribe documents suicidal ideation, homicidal ideation, self-harm, risk level, protective factors, and safety plan elements — providing the documentation that protects both patients and providers.

Can ExamScribe document validated psychiatric rating scales?

Yes. PHQ-9, GAD-7, PCL-5, Y-BOCS, PANSS, ADHD-RS, and other validated tools are built into their respective templates. You enter the scores and ExamScribe incorporates them with clinical interpretation.

Is my patient data used to train the AI?

Never. Your transcripts and patient data are never used to train AI models. All data is processed on HIPAA-compliant Azure servers in the US and auto-deleted on your schedule.

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