Psychiatric Review of Systems Template for Mental Health Professionals (PDF & Word Doc)

A thorough review of systems is the foundation of an accurate diagnostic picture — but psychiatric symptoms rarely exist in isolation from medical status, and medical conditions and medication side effects can both mimic and complicate psychiatric presentations. A combined general medical and psychiatric review of systems helps clinicians screen broadly across both domains in one structured pass, rather than treating them as separate exercises.

TherapyByPro’s Psychiatric Review of Systems is a comprehensive, 23-page clinician-developed screening tool designed for psychiatrists, psychiatric nurse practitioners, and other mental health professionals conducting a broad symptom review. The form combines a General Medical Review of Systems organized by body system with a comprehensive Psychiatric Symptom Assessment organized by DSM-5-TR clinical domain, followed by a medication side effect review, functional impact summary, and clinician summary and clinical impressions.

The form opens with a psychiatric history snapshot — prior diagnoses, hospitalizations, suicide attempts, medication trials, and current treating providers — and a chief symptoms summary capturing the patient’s top presenting concerns before the full domain review begins. The General Medical Review of Systems covers constitutional, cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine/metabolic, musculoskeletal, dermatologic, hematologic/immunologic, and pain domains, with particular attention to findings relevant to psychiatric medication prescribing, such as QTc prolongation history and clozapine ANC monitoring.

The Psychiatric Symptom Assessment then works through symptom domains including mood disorders, manic and hypomanic symptoms, anxiety and related disorders, obsessive-compulsive and related disorders, trauma and stressor-related symptoms, psychotic symptoms, cognitive symptoms, sleep disturbances, eating and weight, impulse control and behavioral symptoms, attention/activity/executive function, substance use, safety and suicidality, personality and interpersonal functioning, and somatic and functional symptoms — each symptom rated as current, past history, denied, or unknown, with a 0–10 severity scale and space for clinical notes.

A dedicated medication side effect review screens for over 25 potential side effects and adverse reactions — including weight change, akathisia, tardive dyskinesia, serotonin syndrome features, lithium toxicity signs, and anticholinergic effects — with fields to document which medication is implicated, severity, and management action. A functional impact summary rates impairment across twelve life domains and links to WHODAS 2.0, PHQ-9, and GAD-7 scoring, before a clinician summary section that synthesizes the most clinically significant findings, safety concerns, medication-related concerns, symptom clusters and diagnostic considerations, and recommended follow-up.

What Is Included in This Psychiatric Review of Systems

This comprehensive review of systems includes documentation commonly used when conducting a broad medical and psychiatric symptom screen:

• Psychiatric History Snapshot: Prior diagnoses, hospitalizations, suicide attempts, medication trials, and current treating providers.
• Chief Symptoms Summary: The patient’s top presenting concerns, ranked by priority, before the full domain review.
• General Medical Review of Systems: Constitutional, cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine/metabolic, musculoskeletal, dermatologic, hematologic/immunologic, and pain domains.
• Psychiatric Symptom Assessment by Clinical Domain: Mood, manic/hypomanic, anxiety, OCD and related, trauma and stressor-related, psychotic, cognitive, sleep, eating and weight, impulse control, attention/executive function, substance use, safety/suicidality, personality/interpersonal, and somatic/functional symptoms.
• Medication Side Effect Review: Over 25 potential side effects with medication attribution, severity, and management action, including akathisia, tardive dyskinesia, serotonin syndrome, and lithium toxicity signs.
• Functional Impact Summary: Impairment ratings across twelve life domains, linked to WHODAS 2.0, PHQ-9, and GAD-7 scores.
• Clinician Summary and Clinical Impressions: Significant positive findings, safety concerns, medication-related concerns, diagnostic considerations, and recommended follow-up actions.

How This Review of Systems Functions in Practice

This form is designed to be completed at initial evaluation, annual review, or before medication initiation, providing a structured, broad-based screen across both medical and psychiatric domains.

• Comprehensive Symptom Screening: Screens broadly across medical and psychiatric domains in one structured pass, reducing the risk of missed findings.
• Medication Safety Monitoring: Systematically screens for medication side effects, including those requiring urgent attention such as serotonin syndrome and lithium toxicity.
• Pre-Procedural and Periodic Use: Supports use before ECT, TMS, or ketamine treatment, and as an annual or periodic update to an existing psychiatric record.
• Diagnostic Hypothesis Generation: Organizes findings by DSM-5-TR domain to support the clinician’s differential diagnosis and follow-up planning.

Documentation Features

• Designed specifically for psychiatrists, psychiatric nurse practitioners, and mental health professionals conducting a broad symptom review.
• Twenty-three pages combining General Medical Review of Systems with a DSM-5-TR-organized Psychiatric Symptom Assessment.
• Covers 15 general medical systems and 15 psychiatric symptom domains with current/past history/denied/unknown tracking and 0–10 severity ratings.
• Includes a detailed medication side effect review covering over 25 potential adverse effects.
• Provides a twelve-domain functional impact summary linked to standardized instrument scores.
• Includes clinician and supervisor signature sections and method-of-administration documentation.

Practical Integration Notes

This form is a clinical screening tool intended to be completed at initial evaluation, annual or periodic review, before medication initiation, or before procedural interventions such as ECT, TMS, or ketamine treatment. Positive findings require further clinical assessment, structured interviewing, and professional judgment before diagnostic conclusions are drawn — this form does not constitute a diagnosis on its own. Clinicians should customize the document to reflect their practice setting and applicable state and licensing board requirements. The completed review should be maintained as part of the patient’s clinical record in accordance with HIPAA and applicable documentation standards.

References

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). Resource
• World Health Organization. (2010). WHO Disability Assessment Schedule (WHODAS 2.0). Resource
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. Resource
• Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. Resource
• Guy, W. (1976). ECDEU Assessment Manual for Psychopharmacology — Revised (Abnormal Involuntary Movement Scale). U.S. Department of Health, Education, and Welfare. Resource