Psychiatric progress notes should document the chief complaint, relevant interval history, mental status examination findings, current medication review including adherence and side effects, clinical assessment with diagnostic impression, treatment plan with rationale for any changes, and risk assessment — this documentation supports clinical continuity, legal protection, and accurate billing

Detailed documentation is only required for initial evaluations; follow-up medication management visits have no specific documentation requirements

The brief notes are adequate because medication management visits are straightforward and do not require detailed documentation beyond confirming stability

The PMHNP should dictate lengthy narrative notes for each visit to maximize billing revenue, regardless of clinical relevance