Templates, Clinical notes, Mental health

Mental health procedure note template

A mental health procedure note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated 16 October 2026. Written by our clinical team, generic by design, with no dosing advice.

01Procedure note

TemplateMental health

Patient: [Name]
Date of birth: [Date]
Record number: [Number]
Clinician: [Name, registration number]
Consultation: [Date and time], [in person or video]

Mental health procedure note, structured assessment

1Indication

Why the structured measures are being used, and at which point of care.

2Consent

How consent was taken, and the risks, benefits and alternatives discussed.
Whether written consent is on the record, with its date.

3Procedure

The validated measures completed, and how they were completed.

4Findings

Scores recorded, and how they compare with the last measurement.

5Complications

Any complication, or a record that there were none.
Anything that did not go to plan, and what was done about it.

6Aftercare and follow-up

Aftercare advice given, verbally and in writing.
Follow-up arranged, and what should prompt the patient to get in touch sooner.

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Procedure note

SignedAI-assisted, edited by the clinician

Patient: Invented patient, for illustration
Clinician: [Clinician name]
Consultation: In person

Mental health procedure note

1Indication

Baseline mood and anxiety measures at assessment.00:50

2Consent

Completed by the clinician from the record.

3Procedure

PHQ-9 and GAD-7 completed by the patient in clinic.02:00

4Findings

Scores recorded in the measures record. Moderate range, consistent with the history.06:00

5Complications

Completed by the clinician from the record.

6Aftercare and follow-up

Measures to be repeated at each review.07:00

Transcript

What was said, and the line of the note it became.

00:50I'd like you to fill in two short questionnaires before we talk.Baseline mood and anxiety measures at assessment.
02:00Answer these about how you've felt over the last two weeks.PHQ-9 and GAD-7 completed by the patient in clinic.
06:00Your scores are in the moderate range, which matches what you've told me.Scores recorded in the measures record. Moderate range, consistent with the history.
07:00We'll repeat these at each review to see how things are changing.Measures to be repeated at each review.

wai writes this note while you talk to the patient

The note, letters and referrals from one consultation, in your own structure, held for your signature. wai keeps this note current, versioned and signed off for you.

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Questions

What goes in a mental health procedure note?

Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. Each section on this page lists what belongs in it, written for mental health.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

The procedure note in other specialties

All clinical notes

Come back to the note, written and ready to sign.

See the wai scribe write a mental health procedure note on your own structure, in a 15 minute video call.

Request a demo Email us

Mental health procedure note, structured assessment

1Indication

2Consent

3Procedure

4Findings

5Complications

6Aftercare and follow-up

How the wai scribe fills it

Mental health procedure note

1Indication

2Consent

3Procedure

4Findings

5Complications

6Aftercare and follow-up

Questions

The procedure note in other specialties

Further reading

Come back to the note, written and ready to sign.