Psychiatry — Medication Management Follow-up Template

The Medication Management Visit Template is designed for psychiatrists, psychiatric nurse practitioners, and physician assistants conducting follow-up visits focused on psychotropic medication optimization. This streamlined template efficiently documents medication response, side effect monitoring, mental status assessment, and treatment plan adjustments required for brief medication management appointments (CPT 99212-99214 with add-on psychiatric services). The template includes focused interval history since last visit, current medication review with adherence assessment, symptom tracking using standardized scales when appropriate, side effect inventory, abbreviated mental status exam, risk reassessment, medication adjustments with rationale, laboratory monitoring when indicated, and brief supportive interventions. This focused structure supports high-quality psychopharmacologic care while maintaining efficiency for typical 15-30 minute medication management appointments. The template facilitates systematic symptom tracking, ensures thorough side effect monitoring, documents medical necessity for medication changes, and supports quality metrics for medication safety and efficacy. Ideal for outpatient psychiatry practices, psychiatric clinics, community mental health centers conducting medication clinics, and integrated primary care behavioral health programs with prescribing providers.