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A medication management follow-up note is a prescriber's record of an established-patient psychiatric visit centered on medications: response, adherence, side effects, monitoring, and plan changes. Psychiatrists, psychiatric nurse practitioners, and physician assistants write one at every med check, billed in the US as an E/M visit (99212 to 99215). Most run 150 to 500 words.
Psychiatrists, PMHNPs, and PAs; prescribing psychologists in the few states that authorize them
The prescriber at the next visit, the care team, payers and their auditors
150 to 500 words · 5 to 10 minutes by hand (clinical team estimate)
Established-patient E/M progress note (compare: psychotherapy progress note, psychiatric diagnostic evaluation)
At every follow-up visit where assessing and adjusting psychiatric medication is the main work
E/M coding rules and payer policy shape the content; no statute in any of the three countries prescribes a format
A medication management follow-up note records an established-patient psychiatric visit whose primary work is pharmacologic: how the medication is working, whether the patient is taking it, what side effects and monitoring results have appeared, and what the prescriber changed. Its structure merged two lineages, the problem-oriented medical record Lawrence Weed published in 1968, ancestor of the SOAP note, and the much older psychiatric interview and mental status tradition. No body ever issued a med-check format; what standardized the note was a coding change. The AMA deleted the standalone medication management code 90862 effective January 1, 2013, with no grace period, moving prescribers onto the general E/M codes, and the January 1, 2021 E/M overhaul then dropped scored history and exam requirements, so the code level now rides on medical decision making or total time alone. The note as practiced today is an E/M artifact governed by general E/M rules, not by anything psychiatry-specific. You will also hear med check, med management note, psych follow-up, med review, and, in Australia, review attendance.
The distinction that carries this page: almost nothing about the note's content is statute. Record-keeping law in all three countries requires that a record exist, be legible, be authenticated, and be retained; the field-level expectations, interval history, medication list, mental status, risk, plan, come from payer policy and professional convention, and the E/M framework itself is AMA convention that becomes payer policy when CMS and commercial payers adopt it. The note differs from the psychiatric diagnostic evaluation, the comprehensive intake generally payable once per episode, and from the psychotherapy progress note a therapist writes for the same patient: this one is prescriber-authored, pharmacologically focused, and coded from the E/M family.
Psychiatrists, psychiatric nurse practitioners, and physician assistants write these notes in outpatient psychiatry practices, community mental health centers, integrated primary care, addiction medicine, and telepsychiatry; prescribing psychologists write them in the handful of states that authorize psychologist prescribing, with 90863 as their add-on code. In collaborative care programs the psychiatric consultant recommends rather than prescribes, so that advice lives in a collaborative care note while the treating prescriber's own visits produce medication management notes. Use this format for routine follow-up. Switch to the psychiatric diagnostic evaluation for a new patient, a new episode after a substantial gap, or a documented major change needing full re-evaluation, and to a consultation report when another clinician asked a question you are answering. The therapist seeing the same patient keeps a separate psychotherapy progress note.
Reason for visit. The condition and today's purpose, stated so medical necessity is visible: 6-week follow-up of sertraline titration for major depressive disorder, not a bare follow-up. Medicare contractor guidance treats a one-word reason as insufficient to support the claim. Pitfall: medical-necessity denials (CO-50) start at the first line; follow-up names an interval, not a reason.
Interval history. What changed since the last visit: symptom course, response to the current dose, adherence with specifics, side effects asked about and answered, sleep, substance use, and stressors. Pitfall: a history copied forward until it contradicts the plan; a JAMA Internal Medicine study of one center's inpatient notes found roughly 46 percent of text copied, and auditors read consecutive notes side by side.
Current medications and monitoring. The full list with name, dose, and frequency, reconciled against what the patient actually takes, plus the monitoring the regimen requires: lithium or valproate levels, metabolic panels on antipsychotics, AIMS at guideline intervals, ECG where indicated. Pitfall: monitoring that lives only in the lab module; results count toward medical decision making only when the note shows they were reviewed.
Examination, mental status, and risk. A medically appropriate exam. Since January 1, 2021 no payer scores its extent, so document what you examined and found, and assess risk, suicidality and, where relevant, violence, whenever symptoms, medications, or history make it pertinent. The full format lives on the mental status exam page. Pitfall: a 12-domain MSE template copied forward unchanged; a shorter exam written fresh is stronger in an audit than boilerplate.
Assessment and medical decision making. Each problem addressed, with status and severity; the data reviewed; the rationale for the medication decision, including the risks weighed; the diagnosis coded to the highest specificity supported. Pitfall: stable, continue meds under a 99214; downcoding clusters on under-described severity and unstated rationale, not on note length.
Plan and prescriptions. Every change paired with its why: dose and titration schedule, new and stopped scripts, labs ordered, the PDMP query where state law requires one, safety-netting instructions, and the follow-up interval. Pitfall: a PDMP check performed but never attested; a minority of states require the note to record the query, and the attestation takes one line.
Billing basis and signature. Either total time on the date of the encounter with a line on what filled it, or medical decision making, plus signature, credentials, and date. When a psychotherapy add-on (90833, 90836, 90838) is billed, the psychotherapy time and content are documented separately and the E/M level is selected by MDM alone. Pitfall: forcing a time entry into an MDM-based note; a documented 15 minutes sitting beside a 99214 does the auditor's work.
MEDICATION MANAGEMENT FOLLOW-UP NOTE Patient: ______________ DOB: __________ Visit date: __________ Prescriber, credentials: ______________________________________ REASON FOR VISIT (condition + purpose, never a bare "follow-up") ________________________________________________________________ INTERVAL HISTORY (course since last visit, response, side effects, sleep, substance use, stressors) ________________________________________________________________ ________________________________________________________________ Adherence: [ ] as prescribed [ ] partial [ ] stopped Missed doses / pattern: ________________________________________ CURRENT MEDICATIONS (name | dose | frequency | start/change date) ________________________________________________________________ ________________________________________________________________ Monitoring reviewed (levels, labs, AIMS, vitals, ECG): __________ EXAM / MENTAL STATUS (medically appropriate scope) ________________________________________________________________ Risk: SI [ ] denied [ ] passive [ ] active Plan/intent: _______ Violence risk (if pertinent): __________________________________ ASSESSMENT / MDM (each problem + status + severity; data reviewed; rationale and risk of the medication decision) 1. ___________________________ [ ] improved [ ] stable [ ] worse 2. ___________________________ [ ] improved [ ] stable [ ] worse PLAN (changes + rationale, scripts, labs ordered, safety-netting, follow-up interval) ________________________________________________________________ ________________________________________________________________ PDMP checked (controlled scripts): [ ] yes, date ______ [ ] n/a BILLING BASIS: [ ] MDM [ ] total time ______ min (encounter date) Psychotherapy add-on: [ ] none [ ] 90833/90836/90838, documented separately (E/M level by MDM when an add-on is billed) Signature / credentials / date: ________________________________
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: a psychiatric nurse practitioner's six-week follow-up of an established patient on a sertraline titration for depression with co-occurring anxiety. All details are fictional.
Medication Management Follow-Up Note. Patient: R.T., 41 · Visit: 07/16/2026 · Prescriber: M. Osei, PMHNP-BC
Reason for visit: Six-week follow-up of sertraline titration for major depressive disorder, recurrent, moderate (F33.1), with generalized anxiety disorder (F41.1).
Interval history: Six weeks at sertraline 100 mg. Mood and energy improved; PHQ-9 today 11, down from 18 in May; GAD-7 9, down from 14. Early nausea resolved by week two; no other side effects reported on direct questioning. Sleep improved, using trazodone 2 to 3 nights per week. No alcohol since April. No missed doses in the past month per pill organizer and refill history.
Medications: Sertraline 100 mg daily (since 06/03/2026); trazodone 50 mg at bedtime as needed (since 05/2026). No supplements. List reconciled with patient. Monitoring: no labs due; weight stable; BP 118/76.
Exam and mental status: Alert, engaged, casually dressed. Speech normal in rate and tone. Mood reported as better; affect brighter, congruent. Thought process linear. No delusional content elicited; denies hallucinations. Cognition grossly intact. Insight and judgment good.
Risk: Denies suicidal ideation, intent, or plan since last visit; no self-harm. No change in access to means; safety plan from intake remains current. Violence risk not indicated.
Assessment and MDM: 1. MDD, recurrent, moderate (F33.1): improved, partial response at 100 mg with residual anhedonia and morning fatigue at week six. 2. GAD (F41.1): improving in parallel. Data reviewed: PHQ-9 and GAD-7 administered today; pharmacy fill history. Options weighed: hold at 100 mg versus increase; residual symptoms at an adequate trial interval support an increase; dose-related side effect risks reviewed with patient, who agrees with the plan.
Plan: Increase sertraline to 150 mg daily from 07/17/2026; counseled on transient GI effects and the warning signs that warrant a call. Continue trazodone as needed. No controlled substances prescribed; PDMP not applicable this visit. Repeat PHQ-9 and GAD-7 next visit. Return in 4 weeks, sooner if worse; after-hours crisis contacts reviewed.
Billing basis: Level selected by medical decision making: two chronic illnesses, one incompletely controlled, with a medication adjustment; time not recorded. Signed M. Osei, PMHNP-BC, 07/16/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsA medication management note is part of the designated record set: patients can read it, it is discoverable, and it carries none of the special protections psychotherapy notes have. Retention is jurisdictional, and the most repeated claim about it is wrong: HIPAA's 6-year rule (45 CFR 164.316(b)(2)) covers compliance documentation, not clinical records. US state boards commonly require 7 to 10 years from the last encounter, longer for minors, and Medicare Advantage risk-adjustment audits reach back 10 years. CPSO in Ontario requires 10 years and recommends 15 because Ontario's Limitations Act lets certain claims begin up to 15 years after the events; CMPA advises 16 in British Columbia. Australia's rule is 7 years from last service, or to age 25 for records collected from a child, split across two instruments (Victoria's HPP 4.2 and NSW's s.25(1)) rather than one national law. No federal statute sets a signature deadline either: CMS's manuals ask for completion during or as soon as practicable after the encounter, the 24-to-48-hour figures come from contractors and institutions, and late entries follow the amendment rules, dated, signed, and never disguised as contemporaneous.
The payer layer is where the format-versus-content distinction earns its keep: no statute prescribes the sections, but the claim stands on their content. Bill by MDM or by total time on the encounter date; if MDM, leave time out entirely. When separately identifiable psychotherapy happens in the same visit, use the add-on codes, document the psychotherapy on its own, and select the E/M level by MDM alone. Supervision changed on January 1, 2026: direct supervision for incident-to services under 42 CFR 410.26 can now be met by real-time audio-video availability, audio-only excluded, and incident-to still never fits a new patient or a new problem. In teaching clinics, 42 CFR 415.184 lets one-way-mirror or video observation satisfy the psychiatric presence requirement. The DEA's telemedicine flexibility for controlled-substance prescribing without a prior in-person exam runs through December 31, 2026, with the permanent framework still pending, so date-stamp any workflow built on it. And keep the program boundaries straight: consultant recommendations in collaborative care belong in a collaborative care note, and chronic-condition coordination time in a chronic care management note, not here.
The audit record for this note type is unusually quantified. CMS's Medicare Learning Network compliance material on outpatient psychiatric care reports a 16.1% improper payment rate, a projected $254.5 million, with 78.3% of it attributed to insufficient documentation against 2.6% for incorrect coding: psychiatry loses these audits on notes, not code choice, by roughly thirty to one. An HHS OIG review of pandemic-era psychotherapy claims found $580 million of roughly $1 billion paid was improper, and Australia's Professional Services Review has ordered individual psychiatrists to repay $100,000 and $500,000 in cases where inadequate records alone were capable of constituting inappropriate practice. The BastionGPT Clinical Advisory Board sees the same errors most often in medication management note reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | The E/M framework is AMA convention adopted as payer policy by CMS and commercial payers; statutes require that authenticated records exist (42 CFR 482.24 in hospitals, state board rules in offices), not what the note contains | A record with basic identifiers is law (Ontario's O. Reg. 114/94, s.18(1)); content expectations are college standards (CPSO, CPSA, CMQ), enforceable through discipline | Record-keeping duties sit in the Medical Board's Good Medical Practice code, section 10.5, a regulatory standard; MBS item rules are payer policy; retention statutes in Victoria and NSW are law |
| Terminology | Med check, med management note, psych follow-up, E/M note | Follow-up visit note, or the provincial fee code itself (Ontario's time-based K-codes) | Review attendance, or the item number (the 300 to 308 face-to-face family, 91827 to 91839 telehealth) |
| What changes | Code selection by MDM or total time; psychotherapy add-ons documented separately; incident-to and teaching-physician rules decide who can author and bill | Time-based K-codes must be supported by recorded time, the closest Canadian analogue to a content mandate; no province specifies mental status exam scope | Items 300 to 308 carry a 50-service annual threshold before lower-rebate items 310 to 318 apply, which shapes visit length; a valid referral is a payment condition |
| Retention | State boards commonly 7 to 10 years from the last encounter, longer for minors; Medicare Advantage audits reach 10 years; HIPAA's 6-year rule covers compliance papers, not charts | CPSO: 10 years from the last entry, or 10 years past majority for minors, with 15 recommended; CMPA advises 16 in British Columbia | 7 years from last service, or until age 25 for records collected from a child (Victoria HPP 4.2; NSW HRIP Act s.25(1)) |
The clinical skeleton travels unchanged: interval history, medication response, an appropriate exam, risk, and a reasoned plan serve a prescriber identically in Boston, Toronto, and Melbourne. What changes is the payment scaffolding around the visit and the retention clock behind it. Document to the clinical standard, then check the coding layer your jurisdiction actually applies, and label each local rule for what it is: law, payer policy, or convention.
BastionGPT is specifically trained, tuned, and clinically tested on medication management follow-up notes.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
Either works for 99212 through 99215, and has since January 1, 2021. MDM usually serves brief but complex visits better. If you select the level by MDM, leave time out of the note entirely; a documented short time beside a higher-level code invites the exact comparison you do not want. If you bill by time, record total time on the date of the encounter and what filled it. One rule is fixed: when a psychotherapy add-on is billed, the E/M level must come from MDM, because psychotherapy minutes cannot also support the E/M.
Yes, when the psychotherapy is significant, separately identifiable, and separately documented. Use the add-on codes 90833, 90836, or 90838 alongside the E/M, never the standalone codes 90832, 90834, or 90837, which trigger the CO-97 bundling denial. Keep the psychotherapy time exclusive: minutes spent on psychotherapy count toward the add-on only, and the E/M level is selected by MDM. Physically separating the psychotherapy paragraph is a convention, not a rule, but it is the convention reviewers reward.
No rule in any of the three countries requires one. Since the 2021 E/M overhaul, US code selection needs only a medically appropriate history and exam; no Canadian college standard or Australian item note specifies MSE scope either. Document what you examined and what you found, at the depth today's visit justified. The full format, when you need it, is on the mental status exam page. A 12-domain MSE copied forward unchanged is a larger audit exposure than a shorter exam written fresh.
No. The AMA deleted it effective January 1, 2013, with no grace period; medication management moved to the E/M codes that day and never returned. Its cousin 90863 exists only for prescribing psychologists in the states that authorize psychologist prescribing, and is never correct for psychiatrists, PMHNPs, or PAs. A template or payer document still built around either code is more than a decade out of date.
Most run 150 to 500 words. No regulator sets a length, and no published time-and-motion study isolates how long psychiatric prescribers spend writing one, so treat any per-note minute figure as an estimate. Completeness beats length: each problem's status and severity, the data reviewed, the rationale for changes, and the risk assessment do the work. A long note assembled by copy-forward is weaker under review than a short one written fresh.
The psychiatric diagnostic evaluation (90791, or 90792 when a prescriber performs it) is the comprehensive intake: full history, diagnosis-setting, generally payable once per episode of care, with Medicare typically allowing one per year. The medication management note is the routine follow-up that rides the E/M family. Re-billing the intake code for a routine reassessment inside a continuous episode is a leading denial, and 90792 cannot be reported with an office E/M by the same provider on the same day. Save the intake format for a new patient, a return after a substantial gap, or a documented major change.
The duty to query is state law in most of the US: 36 states plus DC mandate a check in at least some circumstances. Whether the note must record the query is separately specified by only a minority of states and left unspecified in most, and no primary source anywhere prescribes what the attestation must look like. One dated line satisfies the strictest versions, so most compliance teams standardize it for every controlled prescription. Canada and Australia run prescription monitoring through provincial and state systems with their own documentation rules.
In the US, state rules mostly run 7 to 10 years from the last visit, longer for minors, and HIPAA's 6-year figure applies to compliance documentation, not clinical records. In Canada, CPSO requires 10 years and recommends 15, and CMPA advises 16 in British Columbia. In Australia, keep records 7 years from last service, or until age 25 for records collected from a child. Retention attaches to the whole record, and the medication history is often the part a future prescriber needs most.
Dictate the visit or paste your transcript, and BastionGPT drafts the interval history, exam, MDM rationale, and plan in your clinic's format. Before you sign, it flags what is missing: risk not addressed, monitoring due, a dose change with no rationale, a stray time figure beside an MDM claim, or add-on documentation that is not separated. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.