Psychiatric consultation report and letter: template and outline to download
The structure of a psychiatric observation and consultation report (reason for consultation, history, history of the illness, mental state examination, conclusion), the letter to the primary care physician, and a template to download.
Countries covered : France
As a medical doctor, the psychiatrist maintains a medical record and produces two key documents: the observation / consultation report and the correspondence letter to the primary care physician. Well-structured, they secure the follow-up and coordination of care.
The framework to know
The structure of an observation / consultation report
- Reason for consultation and chief complaint. Expressed by the patient and/or their family/friends.
- History. Personal (medical and psychiatric) and family history.
- History of the illness. Onset of symptoms, number of episodes, previous hospitalizations, triggering factors, substance use, compliance.
- Mental state examination. Presentation and contact, mood and affect, speech and thought process, perceptions, cognition (orientation, memory), insight and judgment.
- Standardized assessments. Brief questionnaires (depression, anxiety, orientation, memory) serving as a baseline.
- Diagnostic conclusion.
- Plan of action. Treatment, follow-up, potential referrals.
The correspondence letter
The letter to the primary care physician (or referring doctor) is a pillar of care coordination. A comprehensive letter prevents diagnostic delays, iatrogenic risks, and redundant examinations. It remains concise: reason and context for referral, clinical summary, diagnosis, treatment initiated, proposed follow-up.
Psychiatric report template to download
Psychiatric observation + correspondence letter, based on the structure above, ready to fill out. Access the PDF by entering your email:
Save time on writing
Between the detailed observation and the correspondence letter, writing eats into clinical time. Start with a fixed template, standardise your mental state examination and conclusion phrasing, and dictate your summary right after the consultation.
This is exactly what Delta does: live note-taking or post-consultation dictation, and the tool generates a structured observation and a letter according to your template, with a longitudinal patient memory that reuses the patient history from one consultation to another (useful for tracking progress under treatment). HDS-certified hosting, GDPR compliant, respecting medical confidentiality.
Frequently asked questions
Does a psychiatrist have to maintain a medical record?
Yes. As a medical doctor, they maintain a medical record and, in addition, a personal observation sheet (art. R.4127-45 of the French Public Health Code).
Are the psychiatrist's personal notes transmissible?
No: they are neither transmissible nor accessible to the patient or third parties, unlike the shareable medical record (excluding these notes).
What does a psychiatric observation contain?
The reason for consultation, history, history of the illness, mental state examination, potential standardised assessments, diagnostic conclusion, and plan of action.
Are consultations with a psychiatrist reimbursed?
Yes: the psychiatrist is a contracted doctor, and their consultations are covered by the Assurance Maladie depending on the sector and the care pathway.
What is the purpose of the letter to the primary care physician?
To ensure care coordination: a comprehensive letter limits diagnostic delays, iatrogenic risks, and redundant examinations.
Cut the time spent on your reports in half
Delta generates your observations and letters from your live note-taking or dictation, while respecting medical confidentiality.
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