What a psychiatric ROS is — and how it differs from a medical ROS
A medical review of systems walks through organ systems (constitutional, cardiovascular, respiratory, and so on) asking for symptoms the patient has not mentioned. A psychiatric ROS does the same thing for symptom domains: it asks the questions that screen for the diagnoses you are not yet treating and the side effects the patient has not volunteered. In a psychiatric note, “psychiatric” in the heading means the systems reviewed are mental-health domains, and the medical ROS is pared down to the systems your medications touch.
Three distinctions keep the ROS useful:
- ROS vs HPI. The HPI develops the presenting problem in depth. The ROS is the sweep for everything else. Symptoms that belong to the chief complaint go in the HPI; the ROS records that the other domains were asked about and what the answer was.
- ROS vs MSE. The ROS is what the patient reports; the MSE is what you observe and test. “Denies AH/VH” is an ROS statement. “Not observed responding to internal stimuli” is an MSE finding. The MSE examples show the observed side.
- ROS vs coding. Since the 2021 office E/M revision, the ROS no longer counts toward the visit level — MDM or time does. That removed the incentive to write “ten-point ROS negative” and left the clinical reason: a documented negative means the question was asked.
The twelve psychiatric domains
Ask each domain at intake. At follow-up, review the domains relevant to the diagnoses under treatment, plus the two screens that change medication decisions (mania and psychosis) and the one that never gets skipped (suicidality).
| Domain | What to ask | What to document |
|---|---|---|
| Mood | Depressed mood, loss of interest, hopelessness, guilt, irritability; diurnal variation | Endorsed symptoms with duration; “denies” for the rest |
| Anxiety | Worry content and controllability, panic attacks, avoidance, somatic symptoms, social anxiety | Panic frequency; what is avoided |
| Mania / hypomania | Decreased need for sleep, elevated or irritable mood for days, racing thoughts, pressured speech, increased activity, risky behavior — ever, not only now; antidepressant-associated activation | Lifetime screen with duration of longest period; “denies all” if negative |
| Psychosis | Auditory or visual hallucinations, paranoia, ideas of reference, thought insertion or broadcasting | Modality, content, command vs non-command, timing |
| OCD | Intrusive thoughts or images, rituals, checking, counting; hours per day | Obsession and compulsion content; time consumed |
| Trauma | Exposure; intrusions, nightmares, avoidance, hyperarousal, negative cognitions | Cluster-level positives; PCL-5 if positive |
| ADHD | Inattention, hyperactivity, impulsivity; onset before age 12; two or more settings | Childhood onset evidence; ASRS score if screened |
| Eating | Restriction, binge eating, purging, compensatory exercise, body-image preoccupation | Behaviors with frequency; weight range |
| Sleep | Onset, maintenance, early waking, hypersomnia, hours, nightmares, snoring or witnessed apneas, restless legs | Hours and pattern; apnea red flags |
| Substance use | Alcohol, cannabis, tobacco and nicotine, stimulants, opioids, sedatives, other; amount, frequency, last use, withdrawal history | Each substance named, even when negative |
| Cognition | Memory, concentration, word-finding, getting lost, managing money or medications — patient- or family-reported | Reported change and informant; test it in the MSE |
| Suicidality and self-harm | Passive and active ideation, plan, intent, means, self-harm, homicidal ideation | Positive or negative, with detail carried to the risk assessment |
Pertinent medical ROS for psychotropics
The medical ROS in a psychiatric note is not a formality: it is the side-effect surveillance for the medications on the list, and the screen for medical conditions that present psychiatrically. Tailor it to the regimen.
| System | Ask about | Because of |
|---|---|---|
| Metabolic / constitutional | Weight change, appetite, thirst, polyuria, fatigue | Second-generation antipsychotics, mirtazapine, valproate, lithium; thyroid disease |
| Neurologic / movement | Tremor, inner restlessness, stiffness, involuntary movements of face or limbs, headache, dizziness, seizure | Antipsychotics (EPS, akathisia, tardive dyskinesia — AIMS), lithium, valproate, bupropion, SSRIs |
| Cardiovascular | Palpitations, chest pain, syncope, orthostatic dizziness | Stimulants, TCAs, clozapine, QT-prolonging agents, alpha-blocking antipsychotics |
| Gastrointestinal | Nausea, diarrhea, constipation, dry mouth, reflux | SSRIs and SNRIs (early), lithium, anticholinergic burden, clozapine (constipation) |
| Sexual / reproductive | Libido, arousal, orgasm, menstrual changes, galactorrhea, pregnancy or lactation status | Serotonergic agents, prolactin-raising antipsychotics; valproate and carbamazepine in people who can become pregnant |
| Endocrine | Heat or cold intolerance, hair loss, hoarseness | Lithium (hypothyroidism), valproate (hair loss), undiagnosed thyroid disease |
| Dermatologic | Any rash, mouth sores, blistering | Lamotrigine and carbamazepine, especially in the first eight weeks or after a dose change |
| Hematologic / infectious | Fever, sore throat, easy bruising or bleeding | Clozapine (neutropenia), carbamazepine, valproate (thrombocytopenia) |
| Genitourinary | Urinary retention or frequency, polyuria | Anticholinergics, TCAs, lithium (nephrogenic diabetes insipidus) |
Positive and negative phrasing examples
A positive finding is documented with enough specificity to act on; a negative finding names what was asked. “ROS negative” names nothing. The three examples below are synthetic.
Intake, positive in several domains:
Follow-up on sertraline, negatives written out:
Antipsychotic surveillance, one positive:
Why it reads this way: each negative names the symptom denied, so a reader knows the screen was done. Each positive carries its own duration, trigger and the patient’s preference — “delayed orgasm, tolerable, no change wanted” is a documented shared decision, while “sexual side effects” alone is an unanswered question at the next visit.
Fill-in template
Delete the domains you did not review. Every bracket that stays in the note is a claim that the question was asked and the patient answered.
Errors to avoid
- “ROS negative” or “10-point ROS negative.” Names nothing, is unverifiable, and reads as a template artifact.
- Negatives that contradict the HPI. A ROS that says “denies sleep disturbance” under an HPI describing early-morning awakening is the internal inconsistency an auditor looks for first.
- Skipping the mania screen in a depressed patient. Especially before starting or increasing an antidepressant. The screen is four questions and it changes the plan.
- Suicidality as a checkbox. The ROS may record positive or negative, but the detail — passive vs active, plan, intent, means, protective factors — has to live in the risk assessment every time it is positive.
- Medical ROS not matched to the regimen. A patient on lithium needs thirst, polyuria, tremor and thyroid symptoms asked about; a patient on clozapine needs fever, sore throat and constipation. A generic list misses both.
- ROS and MSE conflated. “Denies AH/VH; not responding to internal stimuli” mixes the patient’s report with your observation. Keep the report in the ROS and the observation in the MSE, and note when they disagree.
Psynopsis captures the psychiatric ROS and the medication-matched medical ROS from the visit, writes out the pertinent negatives, and flags the side-effect positives for your review. See the feature overview, or the workflows for psychiatrists and PMHNPs. For the observed side of the exam, see the mental status exam examples.
Psynopsis captures what the patient reported across the psychiatric domains and the medical systems relevant to the medications on the list, records pertinent negatives explicitly, and flags the side-effect positives for your review.
Try it on your next visitEducational content for licensed clinicians about documentation practice. It is not clinical advice and does not replace clinical judgment or your organization’s documentation standards. Examples are synthetic and contain no patient information.