The note is the document that captures the clinical encounter. It serves three audiences simultaneously: future you (continuity of care), other clinicians (handoffs, consultations), and — if questions arise later — legal and regulatory review. The note that serves one audience well usually serves the others. The note that serves none of them creates problems on all three fronts.
Standard structure applied consistently. Chief complaint. HPI. Past psychiatric history. Past medical history and medications. Social history elements. Mental status exam. Risk assessment. Formulation. Assessment and plan. Each section gets its content; the structure is predictable so the next reader can find what they need quickly.
Reasoning visible. The good note shows clinical thinking, not just conclusions. "Patient continues sertraline 100 mg with partial response (PHQ-9 down from 18 to 11 over 8 weeks). Given partial response and tolerability, increased to 150 mg with plan to reassess in 4 weeks. If less than full remission, will consider switch to SNRI or augmentation." The reader can reconstruct what you were thinking; they could potentially disagree with the reasoning but they can see what it was.
Specific over generic. "Denies SI" with no context tells the reader nothing. "Endorses passive thoughts of death once or twice weekly; denies plan, intent, or specific means; protective factors include strong marriage and engagement in treatment; safety plan reviewed" tells them everything they need to know. Specificity protects both the clinical work and the chart's value.
Don't boilerplate. Templates are useful for structure; boilerplate content is not. The note that could fit any patient with the same diagnosis isn't capturing the actual encounter. Specifics about this patient, this visit, this clinical reasoning.
Document the same encounter to all three audiences simultaneously. A note written for clinical continuity that's specific, reasoning-visible, and substantive also serves legal protection. The boilerplate note that wouldn't help anyone clinically wouldn't help the clinician in any future review either.
Contemporaneous when possible. The note written immediately after the visit is more accurate than the note written a week later from memory. The patient is recent; the details are fresh; the clinical reasoning is still present in mind.
Brief but complete. Longer notes aren't automatically better. Notes that say what matters efficiently serve readers better than verbose notes that hide the key clinical content.