Depression follow-up
Behavioral health

Blank documentation outlines. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

INTERVAL HISTORY
Changes since the previous visit: [ ]
Symptoms and functional impact as reported: [ ]
Sleep, appetite and energy as reported: [ ]
Stressors and supports: [ ]

MEASURES
Screening tool used, score and date: [ ]
Previous score and date for comparison: [ ]

SAFETY
Suicide risk screening method and result: [ ]
Safety plan reviewed or updated, if applicable: [ ]
Access to lethal means discussed, if applicable: [ ]

TREATMENT
Medication use as reported, response and adverse effects: [ ]
Therapy or counseling engagement: [ ]

ASSESSMENT AND PLAN
Current status and reasoning: [ ]
Medication decisions and rationale: [ ]
Therapy referral or coordination: [ ]
Crisis resources provided: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]