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Medication-management note template
Use this when the visit is primarily about regimen review, side-effect monitoring, and next titration steps—while still capturing safety and a focused MSE.
Template content
Copy or download, then paste into Wavo under My Templates.
Medication-Management Note Current Medications - List psychotropic medications with dose, frequency, and duration on current dose. Interval History - Target symptoms and change since last visit. - Sleep, appetite, energy, concentration, mood, anxiety, and relevant comorbid symptoms. Response & Adverse Effects - Benefit (patient-reported and clinician-observed). - Side effects, tolerability, and adherence barriers. Relevant Findings - Focused mental status and any labs/monitoring discussed (e.g., metabolic labs, levels). Safety - Suicidal ideation, self-harm, agitation, and risk formulation. Assessment - Working diagnoses and medication-related clinical impression. Plan - Continue, adjust, stop, or switch medications with rationale. - Monitoring, education, and follow-up interval.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Prioritizes adherence, response, and adverse effects over narrative therapy detail.
- Fits short med-check visits without losing risk documentation.
- Pairs well with longitudinal patient context in Wavo across visits.
- 115–30 minute med checks
- 2PMHNP medication follow-ups
- 3Titration and side-effect visits
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Current Medications Escitalopram 10 mg daily (6 weeks); trazodone 50 mg qHS PRN. Interval History Anxiety improved from 8/10 to 5/10. Sleep still fragmented 2–3 nights/week. PHQ-9 down from 16 to 11. Denies mania. Response & Adverse Effects Partial response. Mild morning nausea first week, now resolved. Adherent 6/7 days; missed one dose traveling. Safety No SI/HI. Risk low. Assessment MDD with anxious distress, partial response to SSRI. Plan Increase escitalopram to 15 mg daily. Continue trazodone PRN. Recheck in 3 weeks. Discussed delayed therapeutic effect and sexual side-effect monitoring.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
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Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.