Psychiatric Medication Review

Identifying Information:

• Detail the patient’s name or initials, age, gender, and date of today’s consultation

Diagnosis and Clinical Concerns:

• List all known diagnoses and key clinical concerns

Reason for Consultation:

• State that this is a medication review
• Include brief statement giving context to the reason for medication review
• Include information on patient’s progress since last appointment, including improvements, challenges, and observations

Mental Status Examination (MSE):

Provide a short paragraph of no more than four sentences summarising the client’s presentation using standard MSE domains: appearance, behaviour, speech, mood and affect, thought process, thought content, perception, cognition, and insight and judgment. Only include each domain if explicitly mentioned in the transcript or contextual note.

Current Medications:

• List current psychiatric and non-psychiatric medications, including doses and frequencies

Notes on Current Medications:

• Assess adherence to prescribed medication regime, including any challenges
• Note patient reported side effects or concerns about medications
• Detail patient’s assessment of medication effectiveness and changes to symptoms
• Detail patient’s concerns or issues about taking current medications
• Detail psychiatrist’s assessment of impact of current medication regime on patient’s presentation
• Include feedback from psychiatrist on patient’s self-report of medication effectiveness

Plan (Including Changes to Medication):

• Detail recommended changes to medication, including dose adjustments, changes in medication, or discontinuation
• Provide rationale for these recommendations
• Detail any further lab tests, physical health monitoring, or referrals required in relation to medication regime
• Detail any education or information provided to patient regarding medication changes
• Detail any other non-medication recommendations with rationale
• Detail plan for patient follow-up including next appointment details and appointments with other health professionals

Risk:

• Make risk assessment statement regarding suicidal or homicidal ideation, self-harm or harm to others, and risk of relapse
• Include information about past suicide attempts or self-harming behaviour
• Include psychosocial stressors contributing to risk level
• Describe protective factors that mitigate risk