Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Follow-up for major depressive disorder (MDD) / Worsening of depressive symptoms
Subjective (Patient Report):
Describe the patient’s mood and affect (emotional presentation). Are they sad, tearful, hopeless, anhedonic (loss of pleasure)?
Inquire about the severity and duration of depressive symptoms (e.g., depressed mood, feelings of worthlessness, changes in sleep or appetite, psychomotor agitation or retardation, suicidal ideation).
Assess for changes in concentration, decision-making ability, and energy level.
Ask about thoughts of death or suicide. If present, assess intent, lethality, and plan.
Objective (Clinician Observation):
Describe the patient’s appearance, eye contact, psychomotor activity, and speech patterns.
Note any changes in weight, hygiene, or overall presentation compared to previous visits.
Assessment:
Diagnosis: Confirm the diagnosis of major depressive disorder based on DSM-5 criteria.
Severity: Briefly describe the perceived severity of the current depressive episode (mild, moderate, severe) based on symptom presentation and functional impairment.
Suicide risk: Assess the level of suicide risk based on the presence of suicidal ideation, intent, lethality, and plan.
Plan:
Treatment:
Outline the treatment plan based on the severity of the episode and the patient’s individual needs. This may include:
Medication: Discuss the use of antidepressant medication and potential side effects.
Therapy: Recommend individual psychotherapy (e.g., cognitive-behavioral therapy – CBT) to address negative thinking patterns and develop coping skills.
Other interventions: Consider additional modalities like mindfulness training, exercise programs, or group therapy if appropriate.
Safety plan: If suicide risk is present, develop a collaborative safety plan with the patient that outlines steps they can take to stay safe during a crisis (e.g., contacting a crisis hotline, removing means of self-harm).
Referral: Consider referral to a psychiatrist for medication management or a therapist specializing in depression treatment if needed.
Education:
Educate the patient about major depressive disorder, symptoms, treatment options, and the importance of medication adherence and therapy participation.
Discuss the importance of self-care strategies like healthy sleep hygiene, regular exercise, and maintaining social connections.
Provide resources for crisis support and mental health hotlines.
Follow-up:
Schedule follow-up visits based on the severity of the episode and treatment response.
More frequent visits may be needed initially, with intervals gradually increasing as symptoms improve.
Advise the patient to return sooner if they experience worsening symptoms, suicidal thoughts, or have any concerns about medication side effects.