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A psychiatric consultation note records a psychiatrist's or psychiatric nurse practitioner's opinion on another provider's patient: the consult question, a focused history, mental status findings, an impression that answers the question, and numbered recommendations back to the referrer. Consultants write one after each referred evaluation in outpatient, primary care, and specialty settings. Most run 250 to 800 words.
Consulting psychiatrists, psychiatric nurse practitioners, and psychologists answering a referral
The referring provider first, then the shared care team, payers, and auditors
250 to 800 words · 20 to 40 minutes by hand (clinical team estimate)
Consultation report family (compare: consultation-liaison note, consultation report, referral letter)
When another provider requests a psychiatric opinion on their patient; common in specialty and inpatient settings
Structure is convention; the documented request and the report back to the referrer are payer conditions, and law in Ontario
A psychiatric consultation note is the written record of a psychiatrist's or psychiatric nurse practitioner's opinion on another provider's patient: who asked, what they asked, what you found, and what you recommend. It belongs to the consultation-report family that runs across medicine, with the psychiatric layer (mental status examination, risk assessment, a capacity comment when asked) added by convention. The US billing lineage runs from Medicare Carriers Manual section 15506 into the Medicare Claims Processing Manual, and the familiar three Rs mnemonic (Request, Render, Reply) is a coding-community distillation of that guidance, not verbatim CMS text. The inpatient side of this work is owned by consultation-liaison psychiatry, the subspecialty renamed from Psychosomatic Medicine effective January 1, 2018. You will also hear the document called a psych consult, an initial psychiatric consultation, a psychiatric opinion, or, in Australia, a 291 assessment after the MBS item number.
Three documents get conflated here, and the boundary is worth drawing. The psychiatric consultation note is the outpatient or specialty-clinic record that answers a referring provider's question and travels back to them as a report. The consultation-liaison note is the hospital bedside version, written into the shared inpatient chart by a C-L service. The consultation report is the letter a psychologist sends back after a testing referral. What makes the consultation note itself is the consult-question-first structure: the question opens the note and the impression answers it. No US, Canadian, or Australian statute prescribes the headings. What law and payers regulate sits around the note: hospitals must file the results of every consultative evaluation in the medical record, dated and authenticated (42 CFR 482.24), Ontario law requires the record to carry the referrer's name and address, and Medicare has not paid consultation codes since January 1, 2010, when CMS Transmittal R1875CP made them "no longer recognized for Medicare Part B payment." Most template sites still miss all three points.
Outpatient psychiatrists and psychiatric NPs taking referrals from primary care write these constantly, and the same structure serves telepsychiatry consult services, integrated-care practices, geriatric and addiction specialists answering a colleague's question, and psychologists asked for a focused opinion. Write one when another provider asked a question and expects an answer they can act on. If you are starting your own comprehensive workup for a patient entering your care, that is a psychiatric diagnostic evaluation, not a consult. Once you assume ongoing prescribing, the record shifts to a medication management note. If your consulting happens through a registry and caseload review with a care manager, without seeing the patient, that is collaborative care note territory. And the document that opens this exchange from the other side is the referral letter; a good one hands you the consult question ready-made.
Header and referral source. Patient identifiers, consult date, the referring provider with contact details, and how and when the request arrived. In Ontario this is law: the Medicine Act General Regulation requires the consultation record to include the name and address of the referring professional. Pitfall: a consult with no visible request. Reviewers verify the order or referral before they read a word of clinical content, and without it commercial consult codes, OHIP consultations, and MBS 291 do not pay.
Consult question. One sentence, in the referrer's terms. If the referral was vague, clarify it with the referrer and record the sharpened version. Pitfall: copying "please evaluate" forward as the question. The impression must answer this exact sentence, so a mushy question guarantees a mushy answer.
Focused history. History of the presenting problem plus only the psychiatric, medical, medication-trial, substance, and social history that bears on the question. For medication questions, list each prior trial with agent, dose, duration, response, and adherence evidence. Pitfall: reproducing a full intake. A consult that reads like a comprehensive diagnostic evaluation buries the answer and slows the referrer down.
Mental status examination. The findings, with weight on the domains the question implicates: cognition for a capacity question, mood and neurovegetative signs for a depression question. Pitfall: an all-normal templated MSE that contradicts the history. A PHQ-9 of 16 next to "euthymic mood, full affect" reads as cloned text to any reviewer.
Risk assessment. Suicide, self-harm, and violence risk, stated either way, dated to the encounter. Pitfall: silence. The referrer treats your note as the specialist's word on risk; leaving it out hands the ambiguity back to a clinician less equipped to resolve it.
Impression. Diagnostic impression, with the first sentence answering the consult question directly. Add the capacity comment here when that is what was asked. Pitfall: listing DSM labels without a sentence that speaks to what the referrer asked. That is the single most common structural failure in consult reviews.
Recommendations and communication back. Numbered recommendations a non-psychiatrist can execute: agent, dose, titration, monitoring, the re-referral trigger, and who does what. Close with the disposition line: report sent to the referrer (date and route) and whether you assumed care or returned it. Pitfall: no transmission line. In Ontario and Australia the written report is a payment condition; everywhere it is what turns an opinion into a consultation.
PSYCHIATRIC CONSULTATION NOTE Patient: [initials] DOB: __________ Date of consult: __________ Referring provider (name, contact): _________________________________ Request received (date / route): ____________________________________ CONSULT QUESTION (one sentence, in the referrer's terms) _____________________________________________________________________ FOCUSED HISTORY (only what bears on the question) HPI: ________________________________________________________________ Psychiatric history: ________________________________________________ Medication trials (agent, dose, duration, response, adherence): _____________________________________________________________________ Medical history / labs: _____________________________________________ Substance use: ________________ Social context: ____________________ MENTAL STATUS EXAMINATION Appearance / behavior: ________________ Speech: ____________________ Mood / affect: ________________________ Thought process / content: _ Perception: ___________________________ Cognition: _________________ Insight / judgment: _________________________________________________ RISK ASSESSMENT (suicide, self-harm, violence; state it either way) _____________________________________________________________________ IMPRESSION (first sentence answers the consult question) _____________________________________________________________________ Diagnoses: __________________________________________________________ RECOMMENDATIONS (numbered, executable by the referrer) 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ Re-referral trigger: ________________________________________________ COMMUNICATION AND DISPOSITION Report to referrer (date / route): __________________________________ Role: [ ] one-time opinion [ ] follow-up planned [ ] care assumed Consultant 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: outpatient psychiatric consultation for a 42-year-old man referred by his family physician after two unsuccessful SSRI trials for major depressive disorder. The consultant answers the medication question and returns care with a plan. All details are fictional.
Psychiatric Consultation Note. Patient: R.D., 42 · Date of consult: 08/11/2026 · Referring provider: A. Okafor, MD, family medicine · Request received: 08/04/2026, written referral · Consultant: S. Marsh, MD, psychiatry
Consult question: "Is a further medication change appropriate for persistent depressive symptoms after two SSRI trials, and can treatment continue in primary care?"
Focused history: 42-year-old man with major depressive disorder, recurrent; current episode 10 months. Sertraline titrated to 200 mg daily, 12 weeks at full dose: partial response, then plateau. Escitalopram 20 mg daily, 10 weeks: minimal change. Both trials adequate in dose and duration; adherence supported by refill history. PHQ-9 at referral 16. Reports low energy, anhedonia, early waking; appetite intact. No manic or hypomanic history; MDQ negative today. No psychotic symptoms. Alcohol 1 to 2 drinks weekly; no other substances. Medical: hypertension on lisinopril; TSH and CBC within normal limits 07/2026. Working full time; married; no psychiatric hospitalizations.
Mental status examination: Alert, cooperative, casually dressed. Speech normal in rate and tone. Mood "worn down"; affect constricted but reactive. Thought process linear; no delusions; no perceptual disturbance. Cognition grossly intact. Insight and judgment good.
Risk: Denies suicidal ideation, intent, or plan; no history of attempts; no concerns identified on direct inquiry. Protective factors include family support and engagement in care. Routine monitoring appropriate.
Impression: Answering the consult question: a switch in antidepressant class is appropriate, and care can remain in primary care with the plan below. Major depressive disorder, recurrent, moderate (F33.1), with inadequate response to two adequate SSRI trials. No bipolarity, psychosis, or untreated medical contributor identified.
Recommendations:
1. Cross-taper: reduce escitalopram over 1 to 2 weeks while starting bupropion XL 150 mg each morning; increase to 300 mg after 2 weeks if tolerated. No seizure or eating disorder history; monitor blood pressure given hypertension.
2. Repeat the PHQ-9 at 4 and 8 weeks. If the score remains above 10 at 8 weeks on the full dose, re-refer for augmentation options.
3. Refer for structured psychotherapy (CBT or behavioral activation) alongside the medication change.
4. Counsel on regular sleep schedule and alcohol moderation; review at routine hypertension visits.
5. Advise return or contact sooner for mood worsening, emerging suicidal thoughts, agitation, or marked insomnia after the switch.
Communication and disposition: Full report faxed and sent by secure message to Dr. Okafor on 08/12/2026; copy filed in this record. One-time consultation; I have not assumed care. Available for re-consultation if the response stalls after an adequate bupropion trial. S. Marsh, MD, psychiatry. Signed 08/11/2026.
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 consultation note lives in two charts. Your copy sits in your designated record set, and the report you send becomes part of the referrer's record; in Ontario, CPSO expects both the referring and the consulting physician to keep the referral request and the consultation report. Patients can request it, and it travels farther than most psychiatric documentation because it was written to be sent, so write it for the referrer, the patient, and any later reader at once. In US hospitals the filing duty is law: 42 CFR 482.24 requires the results of all consultative evaluations in the medical record, each entry complete, dated, and authenticated by an author identified by name and discipline, with records retained at least 5 years. An inpatient consult also feeds the discharge summary that carries your recommendations out of the hospital, and when staff then help the patient act on those recommendations over the following weeks, that coordination work belongs in a case management note, not in amendments to the consult.
The billing layer is where jurisdictions split, and the split is worth labeling. In the US, Medicare payment for consultation codes ended January 1, 2010 (payer policy); you bill the setting-appropriate E/M code, and the consult structure survives as convention because it still answers the clinical need. Some commercial payers still pay 99242 through 99245 and 99252 through 99255 and expect the documented request, the rendered opinion, and the written reply; others, including Anthem since October 1, 2021, have dropped them, so the payer contract decides the code. In Ontario, the referrer's identity in the record is law, and the written report is payer policy: OHIP consultation codes such as A195 and A190 require a written referral and a written report, with a major consultation limited to one per patient per physician in a 12-month period. In Australia, MBS items 291 and 293 tie payment to the referral and "a detailed written report to the referrer," per the MBS explanatory notes. Across all three countries, the format is a convention; the documented request and the reply are the requirements.
No published audit isolates psychiatric consultation notes; the enforcement record around psychiatric services is specific enough to learn from. HHS-OIG report A-09-21-03021 estimated $580 million in improper Medicare psychotherapy payments in a single pandemic-year audit, and a March 2022 OIG review of one high-volume psychiatrist assessed about $1.1 million in overpayments, citing services by social workers and nurses billed incident-to under the psychiatrist, missing time documentation, and records created months after the encounter. In Australia, the Professional Services Review reported that most inappropriate-practice findings in 2021-22 involved "inadequate clinical notes" and failure to meet MBS item requirements. The BastionGPT Clinical Advisory Board sees the same errors most often in psychiatric consultation note reviews:
BastionGPT is specifically trained, tuned, and clinically tested on psychiatric consultation notes.
See how clinicians use it day to day on the AI therapy notes page.
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Most run 250 to 800 words and take 20 to 40 minutes by hand. The length tracks the question: an inpatient reply in a shared chart sits at the short end, while an outpatient report sent to the referrer with a full medication-trial history sits at the long end. If the note is pushing 1,200 words, it has usually drifted into diagnostic-evaluation territory.
No. No US, Canadian, or Australian statute prescribes a heading set, and there is no Joint Commission deadline specific to consult notes (the 24-hour rule clinicians cite is the history-and-physical rule). What is binding sits around the structure: US hospitals must include the results of all consultative evaluations in the medical record, dated and authenticated (42 CFR 482.24), and Ontario law requires the record to include the referring professional's name and address. Section order, headings, and style are convention.
Not to Medicare. CMS ended recognition of consultation codes on January 1, 2010; bill the setting-appropriate E/M code instead. The AMA deleted 99241 and 99251 in 2023, but 99242 through 99245 and 99252 through 99255 remain active CPT codes that some commercial payers accept when the request, the opinion, and the written reply are all documented (the three Rs). Others have dropped them; Anthem stopped effective October 1, 2021. The payer contract, not the note type, decides the code.
All three answer another professional's request, which is why the names blur. The psychiatric consultation note is the outpatient or specialty-clinic record that answers a referring provider's question and goes back to them as a report. The consultation-liaison note is the hospital bedside version: a C-L service documents in the shared inpatient chart and bills hospital E/M codes. The consultation report is the letter a psychologist writes back after a testing referral. The shared skeleton is question, findings, answer; the setting and the reader change.
The psychiatric diagnostic evaluation (billed 90791, or 90792 with medical services) is your own comprehensive workup for a patient entering, or possibly entering, your care: no outside question, no report-back duty, and typically once per episode of illness. The consultation note is narrower: everything in it is filtered through the referrer's question, and it ends by handing the answer back. The practical test is who asked, and who acts on the answer. If the answer is you, write the evaluation.
It depends on where you practice, and the rule strength differs. In Ontario the record-keeping side is law and the report side is payer policy: the Medicine Act's record regulation requires the referrer's identity in the record, and OHIP consultation codes require a written referral and a written report. In Australia, MBS items 291 and 293 tie payment to "a detailed written report to the referrer." In the US, no statute requires a separate letter: for inpatient consults the note in the shared record has historically sufficed, and commercial payers that still pay consult codes expect a written reply. Wherever you are, a dated transmission line in the note is cheap insurance.
Yes, with the supervision layer documented. For Medicare payment on a resident's consult, the teaching physician must document presence and participation, and psychiatry has its own exception: 42 CFR 415.184 allows the required presence to be met by observation through a one-way mirror or video. PMHNPs may author and bill consults under their own NPI within state scope of practice, and behavioral health services billed incident-to a physician may now be furnished under general supervision under 42 CFR 410.26. State scope rules vary, so check yours.
In US hospitals, at least 5 years under 42 CFR 482.24, with many states requiring 7 to 10 years or longer, and longer again for minors. Ontario's CPSO expects at least 10 years from the last entry for adults, and 10 years past the age of majority for minors, with both the referring and the consulting physician keeping the referral and the report. New South Wales, Victoria, and the ACT require 7 years from the last entry for adults and until age 25 for minors. Keep the outbound report with the note; an audit reads them together.
Yes. Give it the referral letter, relevant chart excerpts, and your dictated findings, and it drafts the question-first note: focused history, mental status examination, an impression that answers the question, numbered recommendations, and the reply letter to the referrer. It can also condense a long chart into the focused history and produce a plain-language version for the patient. 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.