FatigueSubstanceuse concernADHDSelf-harmconcern /suicidalSprain orstrainDepression

Behavioral health

Depression

2 templates in the library cover this condition: Depression, follow-up and Depression (initial).

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Template

Depression, follow-up

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MonthChoose anyFirst line

StatusChoose oneFirst line

PHQ-9Choose one

FunctioningChoose one

AdherenceChoose one

Side effectsChoose any

TherapyChoose one

Suicide and self-harm screenChoose one

Safety measuresChoose any

Medication planChoose one

Additional planChoose any

RefillsChoose any

Follow-upChoose one

Counseling

Keep taking the medicine every day, and do not stop it suddenly; we will plan any change together. Recommended supportive care with an emphasis on regular sleep, daily physical activity, regular meals, time with supportive friends and family, and limiting screens before bed. Return precautions given including worsening mood, new agitation or restlessness, trouble functioning at school or home, side effects from the medication, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

  • Month-year and status lead
  • PHQ-9 trend; remission
  • Functioning at home, school, peers
  • Adverse events (activation, GI, headache, sleep)
  • Therapy status
  • Suicidality monitoring
  • Safety plan and means
  • Medication plan: continue, increase, decrease, switch, taper, none
  • Reassess at 6-8 weeks; consultation; psychiatry; maintenance 6-12 months
  • Follow-up 3 months (1 month after a change)

Return precautions in the template

worsening moodnew agitation or restlessnesstrouble functioning at school or homeside effects from the medication

Sources

Template

Depression (initial)

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Practice wording only: leave out patient details. Nothing typed here is saved or sent.

SeverityChoose oneFirst line

ScreenChoose one

DiagnosisChoose one

InterviewChoose any

Co-occurring concerns presentChoose any

Co-occurring concerns absentChoose any

Suicide and self-harm screenChoose one

Safety measuresChoose any

TherapyChoose any

Medication planChoose one

Additional planChoose any

Follow-upChoose one

Follow-up reasonChoose anyJoins the line above

Counseling

Depression is a common, treatable medical condition, and most teens improve with therapy, medication, or both. SSRIs take several weeks for full effect; early side effects such as stomach upset, headache, or feeling restless are usually mild and fade. Take the medicine every day and do not stop it suddenly. Recommended supportive care with an emphasis on regular sleep, daily physical activity, regular meals, time with supportive friends and family, and limiting screens before bed. Return precautions given including worsening mood, new agitation or restlessness, trouble functioning at school or home, side effects from the medication, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Depression is a common, treatable medical condition, and most teens improve with support, therapy, or medication when needed. Recommended supportive care with an emphasis on regular sleep, daily physical activity, regular meals, time with supportive friends and family, and limiting screens before bed. Return precautions given including worsening mood, trouble functioning at school or home, trouble sleeping or eating, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

  • Severity mild, moderate, severe
  • Screen: PHQ-9 or PHQ-A
  • DSM-5 MDD vs subthreshold vs adjustment
  • Interview the adolescent alone and family
  • Comorbidity: anxiety, substance use, ADHD, trauma, bipolar
  • Safety assessment for suicidality
  • Safety plan, lethal means, third party, emergency contact
  • Psychoeducation; confidentiality limits
  • Treatment goals at home, school, peers
  • CBT or IPT-A
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  • SSRI with boxed-warning counseling; active monitoring for mild; defer
  • Zoloft, Prozac, Lexapro
  • Consultation or psychiatry for moderate-severe or complicating factors
  • Follow-up in 2 weeks (video option)

Return precautions in the template

worsening moodnew agitation or restlessnesstrouble functioning at school or homeside effects from the medication

Sources