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Psychiatric intake notes with AI documentation

Psychiatric intakes are dense: history, MSE, risk, meds, and formulation all need to land cleanly. Wavo captures the encounter and structures it in your intake template—you review and sign.

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The workflow problem

New evaluations take longer to chart than the visit itself. Clinicians either truncate risk and MSE detail or finish notes after hours—especially when juggling PHQ-9/GAD-7 scores, prior psych history, and safety planning.

Realistic example

A 34-year-old presents for first psychiatric evaluation of worsening depression and anxiety. Discusses PHQ-9 16, GAD-7 14, prior sertraline intolerance, passive SI without plan, and sleep collapse since a job change. You need a full intake—not a primary-care SOAP.

Sample output shape

Chief Complaint
“I’ve been anxious and down since I started the new job.”

History of Present Illness
8-week worsening low mood and anxiety; sleep 4–5 hours; PHQ-9 16; GAD-7 14. Functional impairment at work. No mania. Passive SI without plan/intent.

Psychiatric History
Outpatient therapy ongoing. Prior sertraline stopped for GI side effects. No hospitalizations.

Mental Status
… (appearance, mood/affect, thought, cognition, insight/judgment)

Safety / Risk
Passive SI; protective factors present; risk low–moderate; safety plan reviewed.

Assessment / Plan
MDD with anxious distress; start SSRI; continue therapy; follow-up 2 weeks.

What to look for

Key criteria clinicians use when evaluating this type of documentation workflow.

Capture the full intake story

Ambient recording or dictation during the evaluation; Wavo maps content into your psychiatric intake sections.

  • History, MSE, risk, meds, and plan as first-class sections
  • Room for screening scores when discussed (PHQ-9, GAD-7)
  • Works for telepsychiatry first visits

Use your intake template

Start from our psychiatric intake template or paste your clinic’s structure into My Templates.

  • Copyable intake template on the templates page
  • Specialty-generated starters during onboarding
  • Smart Transform when you need a rewrite after generation

Keep longitudinal context

Later med checks and follow-ups benefit from patient context—not a blank page every visit.

  • Prior visit context available in the workflow
  • Consistent structure across clinicians in a practice
  • You remain responsible for the signed note

Evaluation checklist

Questions worth asking before you choose documentation software.

Does the note include MSE and risk—not only HPI?
Can you use your clinic’s intake template?
Are screening scores documented when discussed?
Does telepsychiatry documentation match in-clinic quality?
Can the practice share an organization intake template?

Common questions

Straightforward answers for clinicians and practice leaders evaluating documentation tools.

Can Wavo replace my clinic’s intake packet?

No. Wavo structures the clinical note from the encounter using your template. Intake questionnaires and scoring workflows still live in your existing tools; include scores in the note when you discuss them.

Does this work for PMHNPs as well as psychiatrists?

Yes. The same intake and medication-management templates support psychiatrists and psychiatric mental health nurse practitioners.

Try Wavo on your next visit

Start a free trial and see how Wavo fits your documentation workflow.

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