How to Document Depression Assessment in the History of Present Illness
When documenting depression in your HPI, structure it chronologically and include: (1) the two cardinal symptoms (anhedonia and depressed mood) with their frequency over the past 2 weeks, (2) the seven additional PHQ-9 symptoms (sleep disturbance, fatigue, appetite changes, feelings of worthlessness, concentration difficulties, psychomotor changes, and suicidal ideation), (3) duration of symptoms, (4) functional impairment across specific domains (work/school, home, social relationships), and (5) pertinent risk factors and psychiatric history. 1
Core Structure for Depression HPI
Start with Cardinal Symptoms
Begin by documenting the presence and frequency of the two screening questions from the PHQ-9 over the past 2 weeks 1:
- Anhedonia: "Little interest or pleasure in doing things"
- Depressed mood: "Feeling down, depressed, or helpless"
Rate frequency as: not at all (0), several days (1), more than half the days (2), or nearly every day (3).
Document the Seven Additional Depressive Symptoms
If either cardinal symptom scores ≥2, document the remaining PHQ-9 items 1:
- Sleep problems (insomnia or hypersomnia)
- Low energy/fatigue
- Appetite changes (increased or decreased)
- Low self-view/feelings of worthlessness or guilt
- Concentration difficulties
- Motor retardation or agitation
- Thoughts of self-harm (critical safety item: "Thoughts that you would be better off dead or hurting yourself in some way")
Important caveat: Do not omit the self-harm item even if uncomfortable—omitting it artificially lowers the severity score and weakens diagnostic accuracy. Patients rarely endorse this item in isolation; it typically occurs with multiple other symptoms 2.
Specify Duration and Timeline
Document how long the patient has experienced these symptoms. This distinguishes major depressive disorder (symptoms ≥2 weeks) from persistent depressive disorder (dysthymia, symptoms ≥2 years in adults) 3.
Quantify Functional Impairment
This is essential and often overlooked. Explicitly document impairment in three specific domains 1:
- School/work performance: Academic decline, missed days, decreased productivity
- Home functioning: Self-care, household responsibilities, family relationships
- Social relationships: Peer interactions, social withdrawal, relationship conflicts
Rate impairment as none/minimal, mild-to-moderate, or moderate-to-marked interference with functioning.
Identify Risk Factors and Psychiatric History
Document pertinent history that influences diagnosis and treatment planning 1:
- Prior mood disorder with or without treatment
- Comorbid anxiety disorders or substance use
- Chronic medical illnesses (coronary heart disease, COPD, cancer)
- Disease-related factors (if applicable: recurrent/advanced/progressive disease)
- Social factors: relationship status (single, widowed, divorced vs. partnered), employment status, financial resources, education level (<high school/GED)
Assess Safety Immediately
If any risk of harm to self or others is identified, document this prominently and note immediate actions taken: referral for emergency psychiatric evaluation, one-to-one observation, removal of lethal means, safety plan implementation 1. The presence of psychosis, severe agitation, or confusion (delirium) also warrants emergency evaluation.
Practical Documentation Example
Rather than writing vague statements like "patient reports feeling depressed," structure your HPI like this:
"Patient reports feeling down and depressed nearly every day for the past 3 weeks (score 3/3), with loss of interest in previously enjoyed activities more than half the days (score 2/3). Associated symptoms include difficulty falling asleep most nights, low energy nearly daily, decreased appetite with 8-pound weight loss, feelings of worthlessness, difficulty concentrating at work, and psychomotor retardation. Denies suicidal ideation, intent, or plan. These symptoms have caused moderate impairment in work performance (missing 2-3 days weekly), home functioning (difficulty with basic self-care), and social relationships (withdrawn from friends). PHQ-9 score: 16 (moderate-to-severe range). History includes one prior depressive episode 5 years ago treated with sertraline with good response. Currently unemployed for 6 months, divorced, no current substance use. No comorbid anxiety disorder."
Special Considerations
Cultural sensitivity: Tailor your assessment approach for patients with learning disabilities, cognitive impairments, or cultural differences in expressing emotional distress 2.
Older adults: Depression detection is particularly challenging in this population—be vigilant for atypical presentations 2.
Comorbidities: Always assess for co-occurring psychiatric conditions (anxiety, substance use) and chronic medical illnesses, as these affect both diagnosis and treatment 1.
The PHQ-9 cutoff of 8 (rather than the traditional 10) has better diagnostic accuracy in medical populations and should guide your severity assessment: scores 1-7 (none/mild), 8-14 (moderate), 15-19 (moderate-to-severe), 20-27 (severe) 1, 2.