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Hysio Psychiatry
AI Voice-Driven Reporting for psychiatrists
Within psychiatry, Hysio organises source-bound information on the psychiatric history and mental state examination, medication, the current clinical presentation and risk.
Spoken care information from your care encounter
Psychiatry
A structured report in your professional terminology
From care encounter to report
You work. Hysio documents.
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
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Suited to your work.
- Hysio Psychiatric Intake
- Hysio Psychiatric Follow-up & Medication Consultation
- Hysio Psychiatric Clinical Presentation & Risk Report
- Hysio Psychiatry MDT Meeting & Handover
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How Hysio fits into your workday
More attention for the conversation, less typing afterwards.
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You document the conversation
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
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Hysio creates your report
The information appears under the headings of your chosen report format, so you can review each section.
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You review and copy the report
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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Hysio Psychiatry
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Quick answer Intake, medication consultation and risk report 50 questions with cited sources
Quick answer
Intake, mental state examination and medication
Four documentation formats for the psychiatrist: intake, follow-up and medication consultation, clinical presentation with risk, and MDT meeting with handover. Your psychiatric assessment remains decisive.
For psychiatry, Hysio offers fixed report structures around the psychiatric history and mental state examination, medication, and the current clinical presentation and risk.
- What is voice-driven reporting in psychiatry?
- Hysio is an AI scribe for voice-driven reporting: what you say in a follow-up or medication consultation becomes a psychiatric report. You may know it as AI documentation. There are four formats: intake, follow-up consultation, clinical presentation with risk, and MDT meeting. [1] [2] [3] [4] [5]
- What stays tied to the source?
- Hysio only includes history, mental state, medication, risk and the care plan when you say them out loud. When AI takes on this admin, Hysio adds nothing of its own. [1] [6] [7]
- Who stays in control?
- You, as the psychiatrist. You check the mental state, risk and medication before the report goes into the record. [1] [6] [7]
- Documentation formats 4 profession-specific documentation formats: Hysio Psychiatric Intake, Hysio Psychiatric Follow-up & Medication Consultation, Hysio Psychiatric Clinical Presentation & Risk Report, Hysio Psychiatry MDT Meeting & Handover.
- Source role What is reported, what you see in the mental state examination and your analysis stay separate.
- Boundaries Hysio does not independently take responsibility for adding a psychiatric diagnosis, risk assessment, crisis assessment, classification or choice of medication.
- Responsibility The psychiatrist checks and decides what is ultimately saved.
Voice-driven reporting for the psychiatrist
Which four documentation formats does Hysio have for psychiatrists? #
The profile includes four documentation formats: Hysio Psychiatric Intake, Hysio Psychiatric Follow-up & Medication Consultation, Hysio Psychiatric Clinical Presentation & Risk Report and Hysio Psychiatry MDT Meeting & Handover. They fit a first conversation, a follow-up contact, a current assessment or a meeting. The purpose of the contact determines which format fits; the presence of medication or risk information alone does not determine that. [2] [3] [4] [5]
What is in a psychiatric intake report? #
The intake brings together the referral and request for help, the psychiatric history, the examination and the mental state examination. This is followed by the analysis and the care plan as the psychiatrist has stated them. Information from the patient and family members stays distinct from your own findings. Hysio does not fill in a missing diagnosis or conclusion. [2]
When do you choose a psychiatric follow-up and medication report? #
This documentation format fits a follow-up contact in which you discuss the course, the current clinical presentation and the medication. There is room for the patient's reported use, the experienced effect, side effects and your evaluation. The plan contains the agreements from the conversation. A question about medication does not automatically become a decision to change the treatment. [3]
What goes into the report of a psychiatric MDT meeting? #
The MDT meeting report states the reason for the meeting, the participants and their contributions, the perspective of the patient and family members and the current state of affairs. Explicit decisions stay separate from open points. For actions, the person responsible and the time frame stay visible when they have been agreed. A proposal from one participant is not presented as a joint decision. [5]
What is the difference between a psychiatric intake and an MDT meeting report? #
An intake records the initial examination and the request for help, with history, mental state examination, analysis and care plan. An MDT meeting report is about consultation: who contributed which information, what was decided and who does what? So the MDT meeting does not automatically repeat the whole intake. Only include earlier information that is relevant to the meeting and state where it comes from. [2] [5]
How do the history and mental state examination stay recognisable? #
The history describes the complaints, past history and experiences brought up during the conversation. The mental state examination contains the psychiatric examination as you record it. Hysio keeps both sections recognisable. What the patient says about daily functioning, for example, does not simply become a finding from your examination. You check whether that separation is correct in the report. [2]
Can the psychiatric report contain measurement values that were spoken aloud? #
Yes. Name the instrument, the value and the time of measurement when they are known. Hysio can include that data alongside the other information from the contact. A score is not recalculated from individual answers and a result is not given an independent psychiatric interpretation. So record a professional judgement separately if you want to include one. [2] [4]
Who formulates the psychiatric analysis in the intake report? #
The psychiatric analysis remains the psychiatrist's. Hysio organises the descriptive diagnosis, hypotheses or classification that you have explicitly named. The platform does not derive psychiatric meaning from behaviour or individual statements. If your conclusion is missing, that stays visible. This way, when reading it through, you can distinguish what was provided and which assessment is still missing. [2]
With voice-driven reporting, how do you record what the patient, family members and the referrer say? #
When providing the input, make clear who is saying something. An experience of the patient, information from a family member and a judgement from a referral letter each get their own source attribution in the text. For a letter, also state the date if it is known. Hysio should not merge those contributions into a single finding of the psychiatrist's own. [2] [5]
When do you choose a clinical presentation and risk report instead of an MDT meeting? #
The clinical presentation and risk report is intended for your current psychiatric assessment, with risk enquiry, observations and safety agreements. The MDT meeting report records a meeting and the decisions made during it. Risk information can be relevant in both. So choose based on the contact you are documenting and keep your assessment distinct from contributions by other participants. [4] [5]
Consultation, clinical presentation and MDT meeting
How do you record the referral and request for help at the intake? #
Note the reason for referral and what the patient wants to achieve with the contact. If the referrer asks a different question, you keep it separate. Hysio can organise both perspectives under referral and request for help. A suspicion from the referral does not automatically become your diagnosis. Check whether the wording correctly reflects the discussed purpose of the intake. [2]
How do you include earlier psychiatric information in the intake? #
Use earlier information with a recognisable source and date. Make clear what comes from the past history and what the patient is saying now. An old finding must not reappear unnoticed as the current clinical presentation. Hysio organises the context provided, but does not independently verify whether it still applies. During the contact, state which information has been confirmed, has changed or is still uncertain. [2]
Do you have to repeat the full intake in every follow-up report? #
No. A follow-up report focuses on the course since the previous contact, the current clinical presentation, medication and follow-up agreements. From the intake, only include context that you actually provide and that is needed for this contact. Keep the original date recognisable. This keeps it visible what was newly discussed and what comes from earlier examination. [2] [3]
How is risk information organised in a psychiatric report? #
The clinical presentation and risk report keeps the patient's answers, observations, named risk and protective factors and your professional assessment separate. Also record which moment the information relates to. Hysio does not assign a risk level. A protective factor is not presented as a guarantee, and the absence of a topic does not count as a negative screening. [4]
How do you record what the patient says about medication use? #
State the use as the patient describes it and keep this separate from the prescribed regimen or an earlier medication list. Copy the name, strength, dosage and frequency exactly when they have been mentioned. Where there is a difference, it stays clear which source provides which information. You must check an unclearly spoken medication name; Hysio should not choose a likely variant. [3]
What happens to differing views during an MDT meeting? #
Differing views stay linked to the participants who expressed them. Hysio does not independently turn them into agreement. Note separately whether a decision was made or whether a question remains open. If a clear correction follows later in the same meeting, it must be incorporated recognisably without smoothing over the remaining differences between participants. [5]
How do you record safety agreements and the follow-up? #
Describe what was actually agreed, who is responsible for it and when contact or reassessment takes place. Keep those agreements separate from the risk information on which the psychiatrist bases their assessment. Hysio does not add a safety measure or follow-up time frame. Check in particular that a discussed option is not presented as a final agreement and that open points stay visible. [4]
How do you prevent an observation from becoming a psychiatric conclusion? #
First describe what you observed or what the patient said. Only add your interpretation when you have explicitly formulated it. Hysio must not independently interpret behaviour as a symptom, classification or risk. When reading it through, you therefore check not only the individual facts, but also that the coherence of the text does not suggest a new conclusion. [2] [4]
What if the follow-up contact contains no medication information? #
An empty topic is not filled in with data that seems logical or is assumed from an earlier situation. If medication was not discussed, the report must not suggest that use, effect or side effects were checked. Only add information that you can confirm yourself. The chosen report structure is not proof that every section came up during the contact. [3]
How does change since the previous contact stay visible? #
State what has changed since the previous contact and which source you base that on. A reported change in complaints, your current observation and your evaluation of medication are different sections. With voice-driven reporting, the follow-up report brings them together without automatically carrying over the earlier clinical presentation. Record the conclusion and the agreed follow-up separately, so that the course stays traceable. [3]
Source roles in the psychiatric record
Which context helps to understand a psychiatric report later? #
A report must show which contact the information belongs to, who contributed it and which assessment or agreement was made at the time. For older documents, the document date is also relevant. Hysio organises this context if you provide it. Avoid a single statement without time or source ending up in the text as a permanent characteristic of the patient. [2]
How do you separate the experienced medication effect from your assessment? #
Write down the patient's experience recognisably, for example as a reported change since starting use. Keep your professional evaluation of it separate. Hysio does not turn an experienced effect into a proven cause and does not derive medication advice from the description. If you discuss a link or a change, it must be clear that this is your assessment or decision. [3]
How do you include a literal statement from the patient? #
Use a quotation when the exact wording matters and indicate who made the statement. The words must come from the information provided. Hysio must not invent a more striking quotation or change its meaning. Surrounding text can summarise the conversation, but must keep the distinction between a literal statement and your description of that statement. [2]
How does discussed consent stay visible at handover? #
Record what was discussed about consent, for which information or recipient and by whom. Hysio includes an explicit agreement, but does not infer consent from silence or participation in the meeting. The report also does not independently determine whether data sharing is permitted. Before handover, check the applicable agreements and the information the recipient needs. [5]
What if the history and your current findings differ? #
Record both with their own source and time. A patient may describe a different course than what you observe during the examination; that difference does not have to disappear from the text. Hysio does not independently choose which information is correct. State your assessment of the difference if it has been made, or keep visible which information still needs to be checked. [2]
How do you avoid an unnecessarily extensive psychiatric handover? #
Focus the handover on the discussed recipient and the purpose. Include the relevant current information, explicit decisions and open actions, without automatically repeating all intake data. With voice-driven reporting, say out loud who takes up an action and what still needs to be coordinated. You assess which data is needed and check the final text before it is shared. [5]
How do you distinguish a proposal from a decision in an MDT meeting? #
A proposal describes what someone is considering; a decision states what has been explicitly agreed. Make that difference audible in the meeting or clear in your notes. Hysio should not add implementation or approval because a proposal sounds plausible. Also check the action owner and time frame: they may only appear when they have actually been named. [5]
Which information needs extra attention in psychiatric documentation? #
Information about psychological complaints, medication, risk and personal circumstances can be sensitive. Include what is needed for the care encounter and keep statements from the patient or family members separate from your assessment. Hysio does not add a risk assessment of its own. Check the wording and, before data sharing, decide which information the recipient concerned may and must receive. [2] [4]
How does an external letter stay recognisable alongside current medication data? #
State the sender and date of the letter and make clear which information comes from it. Keep that distinct from the use the patient reports now and from your current assessment. An old medication list does not automatically become the current list. With contradictory data, verification remains necessary; Hysio must not resolve the difference on its own initiative. [2] [3]
Can Hysio derive a psychiatric diagnosis or classification? #
No. Within this profile, diagnosis, hypothesis, classification and risk judgement stay with the psychiatrist. Hysio can organise an explicitly stated assessment and attribute it recognisably to you. A judgement from an external source keeps that source attribution. Without such an assessment, no new psychiatric conclusion should appear in the report, not even in the summary. [2] [4]
Medication, risk and professional judgement
How do you check clinimetrics in the psychiatric report? #
Compare the name of the instrument, the stated score and the time of measurement with your source. Check that a missing result has not been filled in and that an earlier measurement is not presented as current. Hysio should not add a norm value or interpretation of its own. A meaning you give to the measurement must stay recognisable as your assessment. [2] [4]
How do you record behaviour without Hysio interpreting it on its own? #
Describe concretely what you saw or heard, with the context of the contact. An observation is something different from the psychiatric meaning you give it. Hysio keeps those steps separate and should not derive psychopathology from behaviour. If you do state a conclusion, check that it is included correctly and as your assessment. [4]
How do you distinguish old risk information from the current enquiry? #
Give earlier information a source and date and put the current enquiry next to it. A previously described risk or safety agreement does not automatically still apply unchanged. Hysio preserves that time difference in the report. State what was discussed again during this contact, which assessment you are making now and which follow-up agreements have actually been confirmed or adjusted. [4]
How do you prevent unintended medication advice in the report? #
Keep use, experienced effect, side effects, a question from the patient and your decision separate. Hysio must not correct a dosage, suggest a change or add an explanation for side effects. Check medication names and numbers with extra care. An uncertain transcription remains a checkpoint; the platform should never choose on the basis of probability what was meant. [3]
What does the report state for a test that was carried out without a stated result? #
If the source only states that the test was carried out, the result remains unknown. The report instruction uses the following for this: “Test performed, result not documented verbally.” That is not a normal result, nor an indication that the test was abnormal. An announced test remains just an intention. You only add the result when you can verify it. [2] [3] [4]
What if two pieces of medication data contradict each other? #
Leave both pieces of data with their source if the difference has not been resolved. A clear correction during the same conversation can be followed. Hysio does not independently choose between an old list, the patient's report and your notes. Check the name, strength and use before you copy the text and mark what still needs to be checked. [3]
How do you record an intervention and the response to it? #
Distinguish between what was proposed, what was actually carried out and which response was then reported or observed. State the source of that response. The follow-up report can describe this sequence, but Hysio must not invent a causal link or treatment result. Include your evaluation separately if you stated it during the contact. [3]
Does a risk that was not discussed mean there is no risk? #
No. A topic that did not come up is something different from an explicitly asked question to which the patient answered in the negative. Hysio should not summarise silence as safety or absence of risk. Record current answers, observations and your assessment separately. Only the psychiatrist determines what meaning the available information has and what still needs to be asked. [4]
How do you handle psychiatric terms and abbreviations? #
Use the terms you spoke yourself and check whether the transcription reflects them correctly. An unknown abbreviation or unclear word must not be expanded into a likely diagnosis. Keep a classification distinct from a descriptive observation. Voice-driven admin in psychiatry stands or falls on that precision. Hysio organises the professional language provided; you assess whether it keeps its intended meaning in the final report. [2]
What do you check before you use the psychiatric report? #
Read the full report and compare facts, source roles and time references with the contact. Check medication data, negations, your conclusions and the status of decisions or agreements. Also watch for summaries that have unintentionally become more definite. Hysio supports writing up the report, but your review determines which text can responsibly be used in the record or a handover. [2] [3] [4] [5]
Practical questions from psychiatry
How do you prepare the input for a psychiatric intake? #
Make clear that it is an intake and distinguish the current conversation from any earlier information. State who is speaking, which documents you are providing and which date they relate to. State your own assessment and the discussed plan explicitly. This gives the documentation format enough context to organise information without filling in missing conclusions itself. [2]
Why does a psychiatric intake report use fixed sections? #
Fixed sections help you find the request for help, history, examination, analysis and care plan. They also show where information is missing, and that makes admin with AI after an intake verifiable. The structure does not prove that every topic was discussed and is not a completed examination in itself. So check the content of each section, even when the layout of the report looks familiar. [2]
How does your evaluation get its own place in the follow-up report? #
State the professional evaluation explicitly and distinguish it from what the patient experiences or a family member reports. The follow-up report includes a separate section for this. Hysio should not add an analysis or explanation to it. Then check whether the evaluation and the plan match your assessment and the agreements of this contact exactly. [3]
What is the difference between Hysio Supplementary and treatment advice? #
Only the psychiatric intake has Hysio Supplementary: a separate section for possibly missed enquiry and verification points. It does not contain a psychiatric diagnosis, risk estimate or medication proposal of its own. The follow-up, risk and MDT meeting documentation formats do not have this section. A point of attention is also not a recorded fact or treatment decision; you assess whether it is relevant and what happens with it. [2] [3]
Which codes belong to the psychiatric documentation formats? #
Psychiatry has profile code 075 in the Hysio catalogue. The four associated documentation formats run from 075.01 to 075.04. These codes distinguish the report structures within the platform. They are not a professional registration or proof of competence. Choose what fits the contact based on the name and purpose of the documentation format. [2] [3] [4] [5]
Does a Hysio report determine whether you may share data? #
No. A report can record what was discussed about a recipient, consent or handover, but does not determine the lawfulness of data sharing. Consent that was not discussed is not added. You check the applicable agreements, the data needed and the recipient before you share information. A well-organised report does not replace that separate assessment. [5]
What do you do if the chosen psychiatric documentation format does not fit? #
First look at the purpose of the contact: intake, follow-up consultation, current assessment or meeting. Choose another format when it fits better. Do not force missing sections into place with assumptions and do not copy standard text that misrepresents the conversation. If the source contains too little information for a reliable report, you must first add to it or clarify it yourself. [2] [3] [4] [5]
How do you handle a correction during voice-driven reporting? #
Make clear which earlier statement you are correcting and what the correct information is. Hysio can follow an unambiguous local correction. If it remains unclear whether a new statement is a correction or a different source, the difference must stay visible. Check medication, numbers and negations in particular, because a small change there can significantly change the meaning. [3]
What place does medication have in the psychiatric documentation formats? #
The psychiatric follow-up report has a separate medication section for use, effect, side effects and your explicit decision. This makes medication open to discussion without automatically turning it into advice. Hysio does not choose a medicine, dose or change. The documentation format follows the content the psychiatrist provides; it does not take over prescribing authority or treatment responsibility. [3]
How can you see what the client said and what you conclude as the psychiatrist? #
Source-bound means that the report can be traced back to what was said, observed or demonstrably provided. The source and time stay recognisable, and uncertainty does not disappear through summarising. Hysio must not add a psychiatric diagnosis, classification or risk judgement of its own. You check whether the text correctly reflects both the facts and your stated assessment. [2] [3] [4] [5]
Sources
- 1 Hysio: Beroepsprofiel psychiatrie (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-09-01
- 2 Hysio: Hysio Psychiatrische Intake (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-09-01
- 3 Hysio: Hysio Psychiatrisch Vervolg- & Medicatieconsult (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-09-01
- 4 Hysio: Hysio Psychiatrisch Toestandsbeeld & Risicoverslag (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-09-01
- 5 Hysio: Hysio Psychiatrie MDO & Overdracht (interne Hysio-documentatie) Document date: 2026-08-24 Accessed on 2026-09-01
- 6 Rijksoverheid (wetten.overheid.nl): Wet verplichte geestelijke gezondheidszorg (Wvggz) Document date: 2026-09-01 Accessed on 2026-09-01
- 7 Zorgprestatiemodel.nl / adviescommissie zorgvraagtypering ggz: Handleiding zorgvraagtypering ggz Document date: 2026-09-01 Accessed on 2026-09-01
- 8 Richtlijnendatabase (Federatie Medisch Specialisten) / NVvP: Richtlijn Psychiatrische diagnostiek, module Verslaglegging bij psychiatrische diagnostiek Document date: 2026-09-01 Accessed on 2026-09-01
- 9 Zorginzicht.nl (Zorginstituut Nederland): Landelijk Kwaliteitsstatuut GGZ, versie 4.0 Document date: 2026-09-01 Accessed on 2026-09-01
Hysio creates the report. You remain responsible for what you save in the record.