Psychiatric review notes carry a heavier documentation load than most specialties — they need to satisfy Medicare's requirements for the item number billed, AHPRA's clinical record standards, and function as an ongoing risk and progress record that the next reviewer (possibly you, six months from now) can actually rely on. Getting the structure right once means every review afterward is faster, not just more compliant.
What has to be in every review, regardless of format
- Mental state examination, even briefly — appearance, mood, affect, thought form/content, perception, cognition, insight and judgement
- Explicit risk assessment — even when the answer is "no acute risk identified," that has to be stated, not implied by omission
- Response to current treatment — whether the current dose/therapy is working, partially working, or not
- A clear plan — continue, adjust, review timeframe, safety plan status
AHPRA's expectation is that a clinical record allows another practitioner to understand the patient's condition and the reasoning behind treatment decisions without needing to ask the original clinician. A note that only says "stable, continue" fails that test even if the clinical judgement behind it was sound.
The template
Patient: [Name / Medicare number]
Date of review: [Date]
Item number: [e.g. 291 / 293 review]
Diagnosis under review: [e.g. Major depressive disorder]
MENTAL STATE EXAMINATION
Appearance/behaviour, mood, affect, thought form and content, perception,
cognition, insight and judgement:
RISK ASSESSMENT
Suicidality, self-harm, harm to others, current risk level and reasoning:
RESPONSE TO TREATMENT
Current medication/therapy, adherence, side effects, symptomatic change
since last review:
PLAN
Dose or treatment adjustment (if any), next review date, safety plan status,
referrals:
Worked example
Mental state examination: Well-groomed, appropriate affect, mood reported as "better than last month." No thought disorder. No perceptual disturbance. Insight and judgement intact.
Risk assessment: Denies current suicidal ideation. No self-harm since last review. No identified risk to others. Overall risk: low, unchanged from previous review.
Response to treatment: Reports partial response to current dose — improved sleep, mood still low-moderate most days. Adherent to medication, no significant side effects reported.
Plan: Continue current dose, review again in 4 weeks. Safety plan reviewed with patient and remains current. No referral required at this stage.
Where reviewers get caught out
- "No acute risk identified" without the reasoning behind it. A one-line risk conclusion with nothing supporting it reads as a box ticked, not an assessment made — even if the clinical judgement was thorough.
- Treatment response described vaguely ("doing better") instead of tied to specific symptoms or measures. Specificity is what makes a note defensible on review.
- Safety plans mentioned once and never referenced again. If a safety plan exists, each subsequent review should note whether it's been reviewed and whether it's still current — a gap in that trail looks like a gap in care, whether or not one occurred.
- Item number and diagnosis not stated in the note itself, leaving billing and clinical documentation to be reconciled separately if ever questioned.
The actual bottleneck
Most psychiatrists don't need help remembering what a complete MSE covers — the strain is writing it out, in full, after every review, on top of a full list. That's the specific gap ScribeUp is built for: the consult becomes a structured review note — MSE, risk, treatment response, and plan already organised — ready for you to check and finalise in minutes rather than written from a blank page after your last patient.
If review notes are the part of the day that won't compress, try ScribeUp free and see how much of this structure writes itself.
Try ScribeUp free and see how much of this writes itself.
Start free trial