The Depression Assessment template by s10.ai is crafted specifically for Family Medicine Specialists to facilitate detailed evaluations of patients presenting with depressive symptoms. This comprehensive template encompasses sections for chief complaints, history of present illness, past psychiatric history, and mental status examination. It also includes risk assessment, diagnosis, and treatment planning, covering both psychotherapy and medication management. Emphasizing patient education and referrals, this template ensures meticulous documentation and bolsters effective patient care. Perfectly integrated with s10.ai, it streamlines the documentation process, boosting efficiency and precision in clinical practice.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Depression AssessmentChief Complaint:The patient describes ongoing feelings of sadness and hopelessness over the last three months.History of Present Illness:Duration of symptoms: 3 monthsSeverity: ModerateAssociated symptoms: Fatigue, trouble concentrating, and appetite changesPrecipitating factors: Recent job lossPrevious episodes: None reportedImpact on daily functioning: Challenges in maintaining daily tasks and social interactionsPast Psychiatric History:Previous diagnoses: NoneHospitalizations: NoneSuicide attempts: NoneMedications:Current psychiatric medications: Sertraline 50mg dailyPast psychiatric medications and response: NoneFamily History:Mental health disorders in first-degree relatives: Mother with a history of depressionSocial History:Occupation: UnemployedLiving situation: Lives aloneSubstance use: Occasional alcohol useSupport system: Limited, mainly friendsMental Status Examination:Appearance: Well-groomedBehavior: CooperativeSpeech: Normal rate and rhythmMood and affect: Depressed mood, restricted affectThought process and content: Logical, no delusionsCognition: Alert and orientedInsight and judgment: FairPHQ-9 Score:PHQ-9 score: 15Risk Assessment:Suicidal ideation: DeniesHomicidal ideation: DeniesSelf-harm behaviors: NoneDiagnosis:Major Depressive Disorder, moderateTreatment Plan:Psychotherapy: Cognitive Behavioral Therapy, weeklyMedication management: Continue Sertraline 50mg dailyLifestyle modifications: Encourage regular exercise and healthy dietFollow-up appointment: In 4 weeksPatient Education:Information provided about depression: Discussed symptoms and treatment optionsTreatment options discussed: Medication and therapySafety plan if applicable: Discussed emergency contacts and crisis hotlineReferrals:Referred to a psychologist for therapyDisclaimer: Billing codes are only intended as a guide. It is the healthcare provider's responsibility to ensure their appropriateness and accuracy for each consultation.
Key advantages of using this template in clinical practice
Common questions about this template and its usage