CLINICAL · AI SCRIBE

Psychiatric history intake with an AI scribe

Published March 19, 2026 · Updated October 10, 2026

No appointment in mental health generates more writing than the psychiatric intake. In one visit you cover the HPI, past psychiatric and medical history, family and social history, substance use, development, the mental status exam, risk, a diagnostic formulation, and a plan. The note runs several pages. If you prescribe, it is also the note every later medication decision will point back to.

If you have ever blocked off the hour after an intake just to write it up, you know the problem. An AI scribe doesn't shorten the evaluation. You still ask every question. What it removes is the hour of reconstruction afterward. You record the intake, MH Scribe transcribes it when you stop, and you generate a structured draft from that transcript in the intake template you choose. You edit; you don't start from a blank page.

Why intake notes take so long

An intake is not just a long follow-up. Several things make the note harder to write:

Volume of information: A complete psychiatric history in one sitting: chief complaint, HPI, past psychiatric history (medications tried, hospitalizations, prior diagnoses), medical history, family psychiatric history, social and developmental history, substance use, and trauma screening.
Diagnostic complexity: The intake is where you set the differential with DSM-5 specifiers, name your rule-outs, and write out the reasoning behind the formulation. That takes narrative, not checkboxes.
Medication decision rationale: If you prescribe at the intake, you document why this medication, why not the alternatives, what earlier trials showed, and how you weighed risk and benefit. Peer reviewers read this part closely.
The baseline: The intake MSE and scores (PHQ-9, GAD-7, PCL-5, AUDIT-C) are what every later visit gets measured against. A vague baseline makes it hard to show that treatment is working.
Informed consent: Risks, benefits, and alternatives for the plan, especially any medication, along with the patient's understanding and agreement.

What the AI scribe drafts from an intake

After you stop recording, MH Scribe transcribes the session. When you generate the note, the AI sorts the transcript into the sections of the intake template you picked. Here is what a draft looks like, section by section, for a fictional patient.

Chief complaint and history of present illness (HPI)

Why the patient came in, in their words, with onset, duration, severity, what makes it better or worse, and how it affects their life. The draft puts the story in chronological order, which patients rarely tell it in.

Example: 34-year-old female presenting for initial psychiatric evaluation with chief complaint of "I can't stop worrying and it's affecting my work." Onset approximately 8 months ago, coinciding with promotion to management role. Reports persistent worry about job performance, health of family members, and finances. Symptoms present most days, with difficulty controlling worry. Associated symptoms include muscle tension (neck/shoulders), difficulty concentrating at work, irritability with partner, and initial insomnia (takes 1–2 hours to fall asleep). Functional impact: missed 3 work days in the past month, declined social invitations, and reports strain on relationship. Previously managed anxiety with exercise and journaling but reports these strategies are no longer sufficient. No prior psychiatric treatment.

Past psychiatric history

Prior diagnoses, medication trials (dose, duration, response, why it was stopped), therapy history, hospitalizations, and any suicide attempts. You will lean on this section every time you choose a medication.

Example: No prior psychiatric diagnoses. No previous psychotropic medications. Attended 6 sessions of counseling in college (2014) for adjustment to academic stress — reports it was helpful but discontinued when symptoms resolved. No psychiatric hospitalizations. No history of suicide attempts or self-harm. Denies prior ECT, TMS, or ketamine treatment.

Medical, family, and social history

Medical conditions, current medications, allergies, family psychiatric history with the relative and the diagnosis, and the social history: living situation, relationships, work, education, substance use. Trauma and developmental history go in when they came up in the session.

Example: Medical: Hypothyroidism (levothyroxine 50mcg daily, last TSH within normal limits per patient), seasonal allergies (cetirizine PRN). NKDA. Family psych: Mother — generalized anxiety disorder (treated with sertraline); maternal grandmother — "nervous breakdown" in her 40s (details unknown); father — no known psychiatric history; brother — ADHD (diagnosed childhood). Social: Lives with partner of 4 years. Works as project manager at tech company (recently promoted). Bachelor's degree in communications. No children. Substance use: Social alcohol (2–3 drinks/week, no binge pattern), denies tobacco, cannabis, or illicit substance use. AUDIT-C: 2. Trauma: Denies history of physical, sexual, or emotional abuse. No significant childhood adversity reported.

Mental status exam (MSE)

The draft builds a structured MSE from what was said and described in the session: appearance, psychomotor activity, speech, mood and affect, thought process and content, perceptions, cognition, insight, and judgment. A transcript can't see the patient, so check this section hardest and add what you observed. It supports the formulation and records how the patient presented at baseline.

Example: Appearance: Well-groomed, appropriately dressed for the season, appears stated age. Psychomotor: No agitation or retardation; fidgeting noted when discussing work stress. Speech: Normal rate and volume; slightly pressured when describing worry content. Mood: "Anxious and overwhelmed." Affect: Anxious, mildly restricted range, congruent with stated mood. Tearful briefly when discussing impact on relationship. Thought process: Linear and goal-directed; occasional tangentiality when describing worry themes (redirectable). Thought content: Preoccupied with performance at work and health concerns. No delusions, obsessions, or phobias identified. Perceptions: Denies auditory, visual, or other hallucinations. Cognition: Alert and oriented x4. Attention intact to conversation. Memory grossly intact for recent and remote events. Insight: Good — recognizes that worry is excessive and seeking help appropriately. Judgment: Good — making protective decisions (seeking treatment, maintaining employment). SI/HI: Denies suicidal ideation, homicidal ideation, and self-harm urges. No plan, intent, or means identified. Safety factors: supportive partner, employment, treatment engagement.

Assessment and diagnostic formulation

A draft diagnostic impression with DSM-5 criteria, a differential with the evidence for and against each, and a biopsychosocial formulation. Separately, MH Scribe suggests ICD-10 codes mapped to DSM-5 criteria and CPT codes such as 90792, each with its reasoning. The diagnosis is yours; the draft just makes your reasoning faster to write down.

Example: Primary: Generalized Anxiety Disorder (F41.1) — meets DSM-5 criteria: excessive worry more days than not for >6 months, difficulty controlling worry, 4/6 associated symptoms (muscle tension, difficulty concentrating, irritability, sleep disturbance), clinically significant functional impairment (occupational, social, relational). Rule out: Adjustment Disorder with Anxiety (F43.22) — temporal relationship to promotion is notable, but symptom severity and pervasiveness exceed what would be expected for an adjustment reaction. Social Anxiety Disorder (F40.10) — anxiety is not limited to social/performance situations; worry themes extend to health and finances. Medical considerations: Hypothyroidism adequately treated per patient report; recommend verifying recent TSH. Risk level: Low. No SI/HI, no substance misuse, strong protective factors.

Treatment plan

Medication decisions and why, therapy recommendations, labs, referrals, safety planning, and follow-up.

Example: 1) Start sertraline 25mg daily x 7 days, then increase to 50mg daily. Selected based on family history of response (mother), favorable side-effect profile, and efficacy for GAD. Discussed expected timeline (2–4 weeks for initial response, 6–8 weeks for full effect), common side effects (GI upset, headache, initial anxiety increase), and rare risks (serotonin syndrome, activation, bleeding risk). Patient verbalized understanding. 2) Refer for individual therapy — CBT recommended for GAD. Provided three referrals in network. 3) Labs: Request recent TSH from PCP to confirm thyroid stability. CBC, CMP, lipid panel for baseline. 4) Sleep hygiene education provided (stimulus control, consistent wake time, limit screens). 5) Safety plan not indicated at this time — no SI/HI identified. Will reassess at each visit. 6) Follow-up in 3 weeks to assess medication tolerability and titration. Patient agreeable to plan.

What changes for you

The evaluation itself is the same. You take the history, watch the patient, form an impression, and make a plan. The difference is what happens after the patient leaves:

You edit instead of reconstruct. You start from a draft built from the transcript, not from memory and a few scribbled lines. You become the editor of the note rather than its typist.
Structure is handled. Family history doesn't drift into the HPI and medication rationale lands in the plan. Your attention goes to whether the content is right.
Baselines are fuller. Scores, direct quotes, and details the patient mentioned once are in the transcript, so the baseline you document is more complete than one written from recall. You will be glad of it at week twelve.
The intake follows the patient. Every follow-up note builds on it. MH Scribe's continuity view and clinical timeline track medication changes and response from the intake forward, and when a prior authorization or referral comes up, Documents AI drafts the letter from your finished notes.
You can look at the patient. When you aren't taking dictation in your head, you can follow the conversation where it needs to go.

Privacy, consent, and compliance

An intake holds more sensitive material than almost any other visit: trauma, substance use, family psychiatric history, childhood. Before you record one, check four things about the tool:

A BAA, in place before the first recording. HIPAA requires a Business Associate Agreement with the vendor, and the vendor has to meet the Security Rule. Encryption in transit and at rest is an addressable safeguard under the current rule and a widely expected practice, so look for it. MH Scribe's BAA is part of its Terms, so it is in effect from signup.
No training on your data. Audio and session content should never be used to train AI models. MH Scribe commits to that in the BAA.
Patient consent. HIPAA does not require patient consent to use a business associate, but state recording laws and professional ethics codes generally do require you to get consent before recording. Use our guide to introducing AI documentation to patients and the consent form template.
You sign the note. The AI writes a draft. You review it, correct it, and sign it, and the clinical responsibility stays with you.

Choosing an intake template

Which intake template fits depends on your role and setting. Three are common:

Psychiatric Evaluation (prescribers): Full HPI, past psychiatric history, medication history with trial details, medical/surgical history, family history, social history, substance use, MSE, risk assessment, diagnostic formulation with differentials, and medication plan with rationale. This is the standard for psychiatrists, PMHNPs, and PAs.
Psychotherapy Intake (therapists): Presenting problem, relevant history, psychosocial assessment, clinical impressions, and treatment goals. Lighter on medication detail and heavier on psychosocial factors, coping, and goals.
Integrated intake (prescribe and treat): For clinicians who both prescribe and do therapy, one template that carries both the medication elements and the psychotherapy assessment.

MH Scribe includes a Psychiatric Intake template alongside SOAP, DAP, BIRP, and GIRP, and you can build a custom template for whatever intake format your practice uses. You choose the template when you generate the note, not before the session, and you can regenerate the same transcript in a different template if the first one wasn't right. When the note is done, copy it into your EHR whole or one section at a time. For more on formats, see our SOAP vs DAP notes guide or the template comparison.

Spend the intake with the patient, not the chart

Record the intake, pick the template, and review a structured draft with suggested codes. Every account gets 5 free AI notes a month.