Sunday, January 27, 2019

Additional Work On The Review of Systems for Psychiatrists

My post on the review of systems for psychiatrists has had a lot of activity lately so I decided to post my latest update that was designed more for patient completion.  The original goal was to have an ROS that can be used like the one you get when you check in at an internist or surgeon's office.  In the last few years I have been checked in at various offices internists, orthopedic surgeons, ophthalmologists, urologist, and general surgeons) and have seen all of their ROS.  All are relatively brief with just a few symptoms.

The historical context of the ROS is that is seems to have migrated from the physicians exam to the waiting room.  To a skeptic like me the driving force has been the invasion of real medical services by the business and managed care world. That means much less  time with a physician but at the same time requires the physician to document much more. A key piece of that documentation is whether a ROS has been done.  Doing the ROS allows for the physician to bill for a more comprehensive assessment.  Having a completed form by the patient allows incorporation into the note from that day which has essentially become a billing document. I think it is safe to say that has become the primary role of the ROS today.  You will still see your physician for 10 or 15 minutes and they will still ask you some ROS style questions, but they will probably not ask you about the symptoms you endorsed is the waiting room. At least they never asked me.

The traditional role of the ROS is best described in my copy of DeGowin and DeGowin under System Review (Inventory of Systems) (p. 24):

"This is an outline for careful review of the history by inquiring for salient symptoms associated with each system or anatomic region.  Primarily it is a search from symptoms that may have escaped the taking of the present illness.  These symptoms should be memorized and their diagnostic significance learned. In practice, the answers are not written down except when positive. After the physician has fully mastered the outline, we suggest that he ask the questions when he is examining the part of the body to which they pertain...".

This is followed by a list of 20 symptom headline by body symptoms including the Mental status exam as item number 20.

Over the years there have been additional modifications for psychiatric specialists. The item in DeGowin and DeGowin for the mental status exam is really inadequate for psychiatric purposes so that is expanded and is on its own.

There was some ambivalence by members of the profession about the degree of medical care and knowledge required at one point in time.  This led to an expanded "psychiatric review of systems" in some circles that basically looked at symptoms of all of the major categories of psychiatric disorders and counted that as the ROS.  It was modified in some standard interviews that were even used in research.

My methods have always been medically based. That was what my mentors taught me and the patients I have treated over the years required. Psychiatrists can never lose sight of the fact that every medication they prescribe has the potential for causing serious medical illness and side effects. We can also never lose sight of the fact that practically every FDA package insert for a medication has medical contraindications, medical complications, and significant medication x underlying illness interactions. Finally, we deal with common medical morbidities like hypertension with severe long term side effects that cannot be ignored.

It is in that spirit that I offer the ROS.  It covers what I discuss with patients. It has evolved past the original System Review in that it is now common for patients to have detailed information about relevant diagnoses and diagnostic testing that they have had that is directly relevant to their psychiatric care. I have included that where relevant. 

I consider this document to be a starting point.  It is for educational purposes only and I am not recommending that you hand it to all of the patients in your waiting area.  I suggest modifying it for your needs and rewriting for your specific patient populations.  A downloadable Word version is available at the link below.  I dictate all of my evaluations and this form also facilitates that process if you need to list specific systems and positive and negative symptoms.  As an example, if the ROS is completely negative I will list the first three symptoms as negatives in my dictation.

Any feed back from medical psychiatrists would be greatly appreciated.

George Dawson, MD, DFAPA


1: DeGowin EL,  DeGowin RL. Bedside Diagnostic Examination. 3rd Edition.  Macmillan Publishing Co. Inc; New York; 1976: p: 24-26.

Review of Systems As A Word Document 

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