What should be included in a Cerner friendly History of Present Illness (HPI) template for a depression follow-up visit?

Cerner-Friendly HPI Template for Depression Follow-Up

Chief Complaint

• Document the patient's primary concern in their own words (e.g., "still feeling down," "medication not helping," "sleeping better but still tired") 1

Depression Symptom Assessment (PHQ-9 Components)

Systematically document the following nine symptoms over the past 2 weeks, rated 0-3 (not at all, several days, more than half the days, nearly every day): 1, 2

• Anhedonia: Little interest or pleasure in doing things 1
• Depressed mood: Feeling down, depressed, or hopeless 1
• Sleep disturbance: Trouble falling/staying asleep or sleeping too much 1
• Fatigue: Feeling tired or having little energy 1
• Appetite changes: Poor appetite or overeating 1
• Guilt/worthlessness: Feeling bad about yourself or that you are a failure 1
• Concentration problems: Trouble concentrating on things like reading or watching television 1
• Psychomotor changes: Moving/speaking slowly or being fidgety/restless 1
• Suicidal ideation: Thoughts that you would be better off dead or of hurting yourself 1, 3

PHQ-9 Total Score: [Calculate 0-27] 1, 2, 4

• 1-7: Minimal symptoms
• 8-14: Moderate symptoms
• 15-19: Moderate to severe symptoms
• 20-27: Severe symptoms 3, 2

Safety Assessment

Document specific inquiry about: 1, 3, 2

• Active suicidal ideation: Current thoughts of suicide with intent or plan 3, 2
• Passive suicidal ideation: Wishes to be dead without active plan 3
• Homicidal ideation: Thoughts of harming others 1, 3, 2
• Access to means: Firearms, medications, other lethal means 3
• Recent self-harm behaviors or attempts 3, 2

Treatment Adherence and Response

Medication compliance: 1, 5

• Current antidepressant(s), dose, and duration 1
• Adherence pattern: taking as prescribed, missed doses, reasons for non-adherence 1, 5
• Last dose taken 5

Side effects assessment (FIBSER approach): 5

• Frequency of side effects 5
• Intensity of side effects 5
• Burden/impact on daily functioning 5
• Specific side effects: sexual dysfunction, weight changes, sedation, activation, GI symptoms 1, 6, 7

Treatment response since last visit: 1, 8

• Symptom improvement: none, minimal, moderate, significant 1
• Functional improvement: work, home responsibilities, social relationships 1
• Time to response (if applicable): weeks since treatment initiation or adjustment 1
• Previous PHQ-9 score for comparison (minimal clinically important difference is 5 points) 8

Psychotherapy and Psychosocial Interventions

Document compliance and satisfaction: 1

• Attendance at individual or group therapy sessions 1
• Type of therapy: CBT, behavioral activation, problem-solving, couples therapy 1
• Perceived benefit and satisfaction with services 1
• Barriers to attendance if non-compliant 1

Functional Status and Quality of Life

Document impact on: 1

• Occupational functioning: ability to work, productivity, absenteeism 1
• Social functioning: relationships with family/friends, social activities 1
• Self-care and activities of daily living 1
• Overall quality of life and well-being 1

Anxiety Symptoms (GAD-7 if indicated)

If anxiety is a prominent feature, document GAD-7 score (0-21): 1, 2, 9

• 0-4: Minimal anxiety
• 5-9: Mild anxiety
• 10-14: Moderate anxiety
• 15-21: Severe anxiety 1, 2

Medical Contributors and Comorbidities

Document assessment of: 1, 3, 9

• Unrelieved physical symptoms: pain, fatigue, insomnia 3, 9
• Medical conditions potentially causing/exacerbating depression: thyroid dysfunction, stroke, neurological conditions 1, 3, 9
• Substance use: alcohol, cannabis, stimulants, opioids 3, 9
• Medication-induced symptoms: corticosteroids, interferon, beta-blockers 1, 9

Behavioral and Lifestyle Factors

Document: 1

• Physical activity level and structured exercise participation 1
• Sleep hygiene practices 1
• Substance use patterns: tobacco, alcohol, illicit drugs 1
• Social support system and stressors 1

Warning Signs for Treatment Modification

Document presence of: 6, 7

• New or worsening agitation, irritability, or restlessness 6, 7
• Panic attacks 6, 7
• Hostility or aggressive behavior 6, 7
• Impulsivity or acting on dangerous impulses 6, 7
• Hypomania or manic symptoms: extreme increase in activity, decreased need for sleep, racing thoughts 6, 7
• Akathisia (psychomotor restlessness) 6

Assessment and Plan Considerations

Based on above findings, document: 1, 8

• If PHQ-9 decreased by ≥5 points: Continue current treatment, monitor for sustained response 8
• If PHQ-9 unchanged or worsened after 8 weeks of adequate treatment: Consider medication adjustment, dose increase, augmentation, or switch 1
• If poor compliance identified: Address barriers, simplify regimen, consider alternative interventions 1
• If PHQ-9 ≥15 or significant suicidal ideation: Refer to psychiatry/psychology 3, 2
• If new concerning symptoms emerge: Evaluate for bipolar disorder, serotonin syndrome, or medication-induced effects 6, 7