What should be included in the documentation of depression?

Documentation of Depression

Depression documentation must include standardized screening scores, specific symptom assessment, functional impairment evaluation, risk assessment, and treatment response monitoring using validated instruments at defined intervals. 1

Core Documentation Components

Initial Assessment and Screening

• Document PHQ-9 scores with specific cutoffs: none/mild (1-7), moderate (8-14), moderate to severe (15-19), or severe (20-27) symptomatology 1
• Record the presence of core diagnostic symptoms over the past 2 weeks, rated as 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day) 1
• Document the nine specific symptoms: depressed mood, loss of interest/pleasure (anhedonia), sleep problems, low energy, appetite changes, low self-view/worthlessness, concentration difficulties, motor retardation or agitation, and thoughts of self-harm 1, 2
• Include whether symptoms cause functional impairment in home, peer, and school/work settings 1

Risk Factors and History

Document pertinent history and specific risk factors 1:

• Prior mood disorder with or without prior treatment 1
• Comorbid mood and/or anxiety disorders (e.g., GAD), prior/current substance use 1
• Presence of other chronic illnesses (e.g., coronary heart disease, COPD) 1
• Recurrent, advanced, or progressive disease (in cancer patients) 1
• Social factors: singleton status (single, not married, widowed, divorced) versus partnered 1
• Unemployment with or without low financial resources 1
• Lower education (less than high school/GED) 1

Safety Assessment

Every depression assessment must include suicide risk documentation 1:

• Document presence or absence of suicidal ideation, behaviors, and prior attempts 1
• Record availability of lethal means (medications, firearms) 1
• Document adequacy of adult supervision and support 1
• Include emergency contact information and safety plan details 1

Diagnostic Clarification

• Reference DSM-5 or ICD-10 diagnostic criteria when documenting the diagnosis 1
• Document whether symptoms meet criteria for major depressive disorder: at least 5 symptoms present during a 2-week period, with at least one being depressed mood or anhedonia, causing functional impairment 2, 3
• Note any special circumstances: cultural factors, learning disabilities, cognitive impairments, or difficulty detecting depression in older adults 1
• Document screening for bipolar disorder risk before initiating antidepressant treatment, including family history of suicide, bipolar disorder, and depression 4

Treatment Documentation

Initial Treatment Plan

• Document specific treatment goals in key areas of functioning: home, peer, and school/work settings 1
• Record patient and family education provided about depression causes, symptoms, impairments, and expected treatment outcomes 1
• Document discussion of confidentiality limits, including need to involve parents or authorities when risk of harm exists 1
• Record treatment choice and rationale: psychotherapy (CBT, behavioral activation, problem-solving therapy, interpersonal therapy), pharmacotherapy, or combined treatment 1, 3

Ongoing Monitoring

Regular assessment using standardized instruments is mandatory 1:

• Document treatment response at pretreatment, 4 weeks, 8 weeks, and end of treatment using PHQ-9 or MADRS 1
• Include patient-reported outcomes such as QIDS-SR alongside clinician-administered scales 1
• Record assessment of symptom relief, side effects, adverse events, and patient satisfaction at 4 and 8 weeks for pharmacologic treatment 1
• Document adherence to treatment recommendations, including follow-through with referrals 1

Treatment Adjustments

• After 8 weeks, if little improvement despite good adherence, document the revised treatment plan: adding psychological or pharmacologic intervention, changing medication, or referring from group to individual therapy 1
• Record reasons for treatment changes, including poor symptom reduction, low patient satisfaction, or barriers to treatment 1

Critical Timing for Documentation

Document depression screening and assessment at 1:

• Initial diagnosis/start of treatment 1
• Regular intervals during treatment 1
• 3,6, and 12 months after treatment 1
• Diagnosis of recurrence or progression 1
• When approaching death (in cancer patients) 1
• During times of personal transition or reappraisal such as family crisis 1

Common Documentation Pitfalls

Avoid relying solely on electronic abstraction - manual chart review is often required to capture screening, diagnostic tools, treatment discussions, medication details, and follow-up characteristics, as EHR systems frequently fail to capture this information in extractable formats 5

Do not document depression based on screening scores alone - the PHQ-9 score refers to symptom severity, not a clinical diagnosis, which requires comprehensive assessment against DSM-5 criteria 1

Never omit suicide risk assessment - suicide risk is mentioned in 74% of depression educational materials and must be documented in every depression evaluation, as over 50% of suicide victims had depression 1