How to Document Perinatal and Postpartum Mental Health Sessions

Why Perinatal Documentation Requires Its Own Framework

Treating clients during pregnancy and the postpartum period involves clinical complexity that standard therapy documentation templates rarely capture. Perinatal mood and anxiety disorders (PMADs) include postpartum depression, postpartum anxiety, perinatal OCD, postpartum psychosis, and birth trauma responses, each with distinct documentation requirements, risk profiles, and care coordination needs.

What makes this population different from a documentation standpoint:

• Screening tools like the Edinburgh Postnatal Depression Scale (EPDS) are used at defined intervals and scores carry clinical decision thresholds
• Risk assessment must screen for infanticidal ideation in addition to suicidal ideation
• Medication decisions involve two patients simultaneously (the parent and the infant via breastfeeding or in utero exposure)
• Care coordination with OB/GYN, midwives, and pediatricians is clinically necessary, not optional
• Telehealth delivery, which is common in postpartum care, creates its own documentation layer

This guide walks through each of those areas with concrete examples.

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Documenting Edinburgh Postnatal Depression Scale Screening

The EPDS is a 10-item self-report instrument validated for use during pregnancy and up to one year postpartum. Scores range from 0 to 30. Clinical thresholds most widely used in practice:

• Score 10 or above: Elevated depressive symptoms; follow-up indicated
• Score 13 or above: High probability of major depressive episode; urgent evaluation warranted
• Item 10 (self-harm question): Any score above 0 requires immediate risk assessment regardless of total score

What to document every time you administer the EPDS:

• Date of administration
• Total score and individual score on Item 10
• Gestational week or weeks postpartum at time of administration
• Clinical interpretation of the score in context (for example, a score of 10 in a client with known anxiety history has different clinical weight than the same score in a client with no prior mental health history)
• Action taken based on score (continued monitoring, intensified session frequency, referral, crisis plan activation)

Concrete example:

"EPDS administered today, 6 weeks postpartum. Total score: 14 (Item 10: 0). Score consistent with high probability of major depressive episode. Client reports feeling 'empty and exhausted' but denies current suicidal or infanticidal ideation. EPDS result discussed with client. Plan: increase session frequency to weekly, consult with prescribing OB within 48 hours regarding pharmacological support, safety plan reviewed and updated."

Do not reduce the EPDS to a single score in the chart. The score without interpretation and action documentation is not clinically useful to a reviewer and does not demonstrate clinical judgment.

Repeat Administration and Longitudinal Tracking

For ongoing perinatal clients, document EPDS scores at each administration in a way that allows longitudinal comparison. A brief table in a progress note or treatment summary is more useful than a score buried in narrative text:

This format supports treatment plan documentation, medical necessity justification, and clear communication to any covering provider.

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Perinatal Risk Assessment: Documenting Beyond Standard Suicidal Ideation

Standard risk assessment frameworks used in general outpatient practice do not fully address the perinatal context. You need to assess and document two distinct risk dimensions.

Suicidal Ideation

Document using the same structured format you use in any high-risk population: presence or absence of ideation, frequency, intensity, plan, intent, access to means, protective factors, and any history of prior attempts. Perinatal clients are at elevated risk, particularly in the first 12 weeks postpartum, and this context should appear explicitly in your clinical formulation of risk level.

Infanticidal Ideation

Infanticidal ideation, thoughts about harming or killing the infant, is a clinical presentation many therapists are not trained to assess or document systematically. There are two qualitatively different presentations:

Ego-dystonic intrusive thoughts (consistent with perinatal OCD): The parent is frightened by the thought, does not want to act on it, and goes to lengths to avoid situations that trigger it. This presentation is not a crisis, but it does require documentation of the thought content, the client's distress response to it, the degree of avoidance behavior, and the differentiation from ego-syntonic ideation.

Ego-syntonic ideation (associated with postpartum psychosis): The parent does not experience the thought as foreign or distressing, may have a rationale for the harm, or may be experiencing command hallucinations. This is a psychiatric emergency requiring immediate action.

Documentation language for ego-dystonic intrusive thoughts:

"Client disclosed recurrent intrusive thoughts of dropping the infant, which she describes as unwanted, distressing, and inconsistent with her intentions and feelings toward her child. She reports increased avoidance of the staircase in her home and hands the infant to her partner when the thoughts arise. She denied any desire or intent to act on these thoughts. Clinical formulation: presentation consistent with perinatal OCD with ego-dystonic infanticidal ideation. Not assessed as acute safety risk. ERP psychoeducation provided. Will monitor at each session."

Documentation language for ego-syntonic ideation or psychosis screen positive:

"Client expressed concern that her infant 'would be better off not existing.' When asked to elaborate, she described the thought as comforting rather than distressing. Denied command hallucinations during this session but displayed disorganized speech and tangential reasoning. Emergency consultation with supervising psychiatrist conducted during session. Safety plan activated. Partner present in waiting room; informed of need for immediate psychiatric evaluation. Referral placed for inpatient psychiatric evaluation. OB notified by phone at [time]. Documentation of notification logged."

The distinction between these two presentations must be explicit in the note. A note that says only "denied intent to harm infant" fails to communicate which clinical presentation you assessed.

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Medication Documentation During Pregnancy and Breastfeeding

Therapists who are not prescribers still have documentation responsibilities around medication in the perinatal context. This is one area where coordination notes matter significantly.

What Therapists Document

• Client-reported medications including dose and prescriber name
• Client-reported concerns about medication safety during pregnancy or breastfeeding
• Psychoeducation provided (for example, correcting misinformation about antidepressant use during pregnancy)
• Recommendations made to consult with the prescriber about a medication concern
• Confirmation that the referral or consultation occurred (follow up and document)

Example note section:

"Client expressed reluctance to continue sertraline 50mg (prescribed by Dr. Reyes, OB-GYN) due to concerns about infant exposure through breast milk. Psychoeducation provided regarding current evidence on sertraline and breastfeeding, including that sertraline is among the most studied SSRIs in lactating populations and that untreated severe postpartum depression carries its own risks to infant development. Client agreed to discuss concerns directly with Dr. Reyes before making any changes. I will follow up with client next session to confirm consultation occurred. Coordination note sent to Dr. Reyes's office today."

If the prescriber is a psychiatrist rather than the OB, document that relationship separately. Note the prescriber's name, specialty, and the date of any communication.

When a Client Stops Medication Without Telling the Prescriber

This happens in perinatal populations more than in general outpatient practice, often because clients fear judgment or are acting on misinformation from social media or family members. When you learn about it:

1. Document what the client told you and when
2. Document clinical indicators of symptom change you observed
3. Document the conversation you had about the decision
4. Document the referral back to the prescriber
5. Follow up and document the outcome

Do not treat this as a routine lifestyle choice. Abrupt discontinuation of psychiatric medication during the perinatal period carries specific risks that warrant documentation of your clinical response.

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Coordinating Care with OB/GYN and Pediatricians

Perinatal mental health care rarely succeeds in isolation. Your documentation needs to reflect the coordination that is actually happening and create a record that is useful to other providers.

Releases of Information

Document the specific ROI the client has signed, which providers are included, and the scope of information permitted for release. Perinatal clients often have multiple providers: an OB or midwife, a pediatrician, sometimes a maternal-fetal medicine specialist, and potentially a prescribing psychiatrist. Each requires a separate ROI unless a blanket release covers all named providers.

Document the date the ROI was signed, the expiration date if applicable, and any limitations the client placed on what can be shared.

Coordination Notes

When you send a coordination note or receive one, document:

• Date of communication
• Provider name and their role
• Method (phone, secure message, fax, letter)
• Content summary (what you shared and what you received)
• Any clinical action taken as a result

Example:

"04/07/2026: Coordination note faxed to Dr. Nguyen, OB-GYN (signed ROI on file, dated 03/15/2026). Summary shared: current EPDS score of 14, current diagnosis of F32.1 (major depressive episode, moderate), current treatment plan including weekly individual therapy and safety planning. Requested: prescriber's assessment of pharmacological support options given client's breastfeeding goals. Response received via fax 04/08/2026: Dr. Nguyen will discuss medication options at next prenatal visit (04/15/2026). Client informed."

Pediatrician Coordination

Pediatricians are on the front lines of postpartum screening through well-child visits. When a pediatrician refers a postpartum parent to you, document the referral source, the concern communicated, and your follow-up communication. When you are the one initiating contact with the pediatrician, document the clinical reason: for example, the parent's postpartum depression is affecting their capacity to respond consistently to the infant's cues, and the pediatrician should be aware.

This type of documentation supports continuity of care and demonstrates that you are functioning as part of an integrated care team, which matters for treatment plan reviews and utilization management.

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Telehealth Documentation for Postpartum Clients

Telehealth is common in postpartum care because new parents face significant logistical barriers to in-person attendance. The documentation requirements specific to telehealth in this population include the following.

Platform and Location

At the start of each telehealth session, document:

• The platform used
• The state where the client is physically located
• Confirmation that you are licensed in that state (if your licensure is limited)
• A brief note about the clinical appropriateness of telehealth for this client's current presentation

Why the location matters: Postpartum psychosis or severe self-harm risk may require a different response plan when the client is not in your office. Document the address of the client's physical location so that emergency responders can be dispatched if needed.

Infant Presence During Sessions

Many postpartum clients conduct sessions while caring for an infant. Document when the infant is present:

• Note the infant's status (sleeping, awake and calm, distressed)
• Note whether infant care needs interrupted the session and how this was handled
• If clinical content was interrupted or cut short due to infant care, document what was deferred and addressed in the next session

Technology and Privacy Considerations

Document that the client confirmed they were in a private location and that other adults were not present (unless the client has invited a partner, in which case document that consent). For clients with intrusive infanticidal ideation, telehealth sessions may require more explicit safety planning because the client is at home with the infant during the session, not sitting in a waiting room where they can be separated from their child if a crisis arises.

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Billing for Perinatal Mental Health Services

Most perinatal mental health sessions are billed using standard outpatient psychotherapy CPT codes. A few considerations are worth noting.

CPT Codes

• 90837 (60 minutes): Most appropriate for complex perinatal cases involving risk assessment, coordination documentation, and active safety planning
• 90834 (45 minutes): Used when session content is more focused and risk is stable
• 90791 (psychiatric diagnostic evaluation): Appropriate for initial assessment sessions that involve formal PMAD screening and diagnosis

The 90837 is commonly appropriate in the early weeks of postpartum treatment, even when the presenting symptom severity appears moderate, because the session work includes screening administration, coordination planning, safety protocol review, and psychoeducation in addition to therapeutic intervention.

Diagnosis Codes

Common ICD-10-CM codes for PMAD billing:

• F53.0: Postpartum depression (mild to moderate)
• F53.1: Postpartum psychosis
• O99.340: Other mental disorders complicating pregnancy (first trimester)
• O99.343: Other mental disorders complicating pregnancy (third trimester)
• F41.1: Generalized anxiety disorder (for perinatal anxiety without depressive features)
• F42.2: Mixed obsessional thoughts and acts (for perinatal OCD)

Note that F53.0 and F53.1 are postpartum-specific codes. Using F32.x (major depressive episode) for a postpartum presentation is not incorrect, but F53.0 provides greater diagnostic specificity when the onset is clearly postpartum. Some payers require F53.0 for perinatal mental health billing. Verify with the client's insurance plan.

Session Length and Medical Necessity

When billing 90837 for perinatal sessions that may feel like "just talking," your medical necessity documentation needs to be explicit. Include in your assessment section:

• Current EPDS score or symptom severity rating
• Functional impairment (bonding difficulties, sleep impairment, inability to care for the infant independently)
• Active safety considerations
• Coordination activities completed during or as a result of the session

A note that documents only "explored postpartum adjustment themes" will not support medical necessity for a 90837. A note that documents EPDS score of 14, active safety plan review, coordination with OB, infant bonding difficulty affecting feeding consistency, and ERP protocol for intrusive thoughts will.

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Common Documentation Mistakes in Perinatal Mental Health

Collapsing Infanticidal Ideation into Suicide Risk

Writing "denies SI/HI" does not address infanticidal ideation in a perinatal context. "HI" typically means homicidal ideation toward another adult. Infanticidal ideation is clinically distinct and requires its own documentation item.

Failing to Differentiate Perinatal OCD from Ego-Syntonic Ideation

A note that says "client reports thoughts of harming infant, denies intent" does not communicate whether the thought is ego-dystonic (OCD presentation) or ego-syntonic (psychosis risk). The clinical distinction is critical. Document the quality of the thought and the client's relationship to it.

EPDS Score Without Context

A score of 12 means different things at 2 weeks postpartum versus 10 months postpartum, in a first-time parent versus a parent with a prior postpartum episode, and in a client who is sleeping four hours a night versus one with adequate sleep. Document the clinical context that frames your interpretation.

Coordination Without Documentation

Calling the OB and not charting the call leaves a gap in the clinical record. Date, provider, method, content, and follow-up plan. Every coordination event gets a line in the chart.

Telehealth Location Not Recorded

If a crisis occurs during a telehealth session and you do not have the client's physical address on file, emergency dispatch is delayed. Document the client's location at the start of every telehealth session.

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A Note on Workflow

Perinatal sessions often generate multiple documentation tasks in a short window: the session note itself, a coordination note to the OB, an updated safety plan, and sometimes an EPDS tracking table. Therapists treating this population benefit from note templates that include EPDS fields, infanticidal ideation assessment prompts, and coordination log sections by default. NotuDocs allows you to build a perinatal-specific template that surfaces all required fields in a single workflow, so you are not reconstructing the structure from a blank note after each session.

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Perinatal Mental Health Documentation Checklist

EPDS Screening

• Date of administration and weeks pregnant or postpartum recorded
• Total score documented
• Item 10 score documented separately
• Clinical interpretation written (not just the score)
• Action taken based on score documented

Risk Assessment

• Suicidal ideation assessed and documented using structured format
• Infanticidal ideation assessed and documented as a distinct item
• Ego-dystonic vs ego-syntonic quality of any infanticidal thoughts documented
• Protective factors documented
• Safety plan reviewed, updated, and dated

Medication Coordination

• Current medications listed with dose and prescriber
• Client concerns about medication safety documented
• Psychoeducation provided noted
• Referrals back to prescriber documented with follow-up plan

Care Coordination

• ROI on file for each relevant provider, with scope and date
• Every coordination communication logged: date, provider, method, content, outcome
• Pediatrician communication documented if infant wellbeing was discussed

Telehealth

• Platform documented
• Client's physical location documented at session start
• Infant presence noted if applicable
• Safety plan adapted for at-home session context

Billing

• CPT code selected matches session length and complexity
• ICD-10-CM code used reflects postpartum onset when applicable (F53.0 vs F32.x)
• Medical necessity documentation includes functional impairment, safety considerations, and coordination activities

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Postpartum therapy documentation that does justice to the clinical complexity of PMADs is more time-consuming than a generic progress note, but it is also more clinically useful. The same note that protects you in a licensing board review is the note that a covering provider can actually act on when you are unavailable.

Related reading:

• How to Document Crisis Intervention and Suicide Risk Assessments
• How to Document Therapy Sessions Using Standardized Outcome Measures
• How to Write a Therapy Treatment Summary for Referring Physicians