Child and Adolescent Psychiatry Documentation With AI: Developmentally Informed Notes
Child and adolescent psychiatry blends patient interview, caregiver history, collateral information, and developmental assessment — often in one short visit slot.
AI documentation must reflect who said what, developmental stage, and safety planning — not adult psych templates with swapped pronouns.
CAP documentation essentials
- Chief concern from patient and caregiver perspectives
- Developmental, academic, and social functioning
- Psychiatric review of systems developmentally appropriate
- MSE adapted for age (observe play, interaction, mood, thought content)
- Safety assessment including custody and access to means context
- Medication discussion with weight, sleep, and academic side effects
- Care coordination with school or therapists when applicable
Psychiatry specialty page | Pediatrics.
Recording and consent
Pediatric visits involve guardians and minors — follow institutional policy on recording and document assent/confidentiality boundaries for adolescents.
Templates: intake vs med follow-up vs therapy overlap
- CAP new patient evaluation
- Medication management with caregiver present
- Adolescent solo portion documentation (per policy)
School and collateral information
Document source of school reports ("parent reports teacher concern...") — do not present hearsay as direct observation.
School-based counseling documentation.
Risk documentation
Same rule as adult psych: manual review of all safety language.
Start a free Wavo trial with CAP-specific templates.