Psychiatric documentation has unique needs — structured assessments, medication interaction checking, and longitudinal symptom tracking. Here's how Clinit approaches them.
Why Generic EMRs Fail in Psychiatry
A generic clinical notes field can capture anything — but capturing structured psychiatric data in free text destroys the ability to track outcomes, audit quality, or research your own patient population. Psychiatric documentation works best when it follows validated frameworks.
Structured Assessments in Clinit Psychiatry
Initial Psychiatric Assessment:
- Chief complaint, history of presenting illness
- Mental state examination (appearance, behaviour, speech, mood/affect, thought form/content, perception, cognition, insight/judgement)
- Psychiatric history, family history, psychosocial history
- Risk assessment: suicidal ideation, homicidal ideation, self-neglect, vulnerability
- DSM-5 / ICD-11 diagnostic formulation
Session Notes:
- SOAP format with quick-select chips for common mental state descriptors
- Scale administration: PHQ-9, GAD-7, MADRS, YMRS, PANSS, PCL-5, AUDIT-C
- Medication review: dose changes, side effects, adherence
Medication Safety
Psychiatry uses polypharmacy more commonly than most specialties, and drug-drug interactions in this field carry real consequences. Clinit's drug interaction checker is run at every prescription save, with severity ratings (minor/moderate/severe) and suggested alternatives.
Longitudinal Scale Tracking
PHQ-9 and GAD-7 scores are charted over time. The patient and clinician can see a trend chart showing how symptoms have changed relative to treatment changes — a compelling visual for both engagement and evidence-based adjustment.
