Psychiatric Medication Review Note
Created by
Rebecca Thompson
Specialty
Psychiatrist
Last edited
10/20/2026
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About this template
A structured template for documenting a patient's current psychiatric medication regimen, including adherence, side effects, effectiveness, and concerns. It also organises the assessment, medication plan, education, testing, and follow-up information.
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Date: 14/05/2024
Patient: Lachlan Mitchell, 34, Male
Current Medications
sertraline (Zoloft®) 100 mg PO OD quetiapine (Seroquel®) 25 mg PO NOCTE PRN
Medication Adherence
Reports taking sertraline consistently each morning; misses approx. 1 dose per fortnight due to shift work. Uses quetiapine 2–3 times weekly for insomnia.
Side Effects
Mild morning grogginess following nocturnal quetiapine use. No GI upset, sexual dysfunction, or weight changes from sertraline.
Effectiveness
Reports significant reduction in baseline anxiety and panic frequency since increasing sertraline to 100 mg 6 weeks ago. Mood is stable. Sleep onset improved with PRN quetiapine.
Concerns and Issues
Concerned about morning sedation impacting early morning shifts and potential long-term reliance on quetiapine for sleep.
Assessment of Medication Regimen
- Current regimen of sertraline 100 mg PO OD is appropriate and well-suited for managing the patient's depressive and anxious symptoms.
- Morning sedation from PRN quetiapine mildly impairs early morning occupational functioning; sertraline is well-tolerated without adverse effects on well-being.
- Good clinical response to sertraline with marked symptom reduction. Insomnia partially managed.
- Minor adherence issues with sertraline secondary to rotating shift schedule.
Plan
- Adjustments to Medication: Liaison with prescribing GP recommended to continue sertraline 100 mg PO OD, halve quetiapine (Seroquel®) to 12.5 mg PO NOCTE PRN, and gradually cease as CBT-I strategies take effect.
- Additional Testing: Re-administer DASS-21 and ISI in 4 weeks to monitor symptom trajectory.
- Patient Education: Discussed sleep hygiene, stimulus control, and taking quetiapine at least 9 hours prior to wake time to minimise hangover sedation. Advised setting a daily phone alarm to standardise sertraline dosing across shifts.
- Follow-Up Plan: Review in 2 weeks for ongoing psychological therapy and medication monitoring.
"Thank you,"
Dr Sarah Jenkins
Clinical Psychologist
Practice number: 4829103B
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.