Primary Care — Depression Follow-up Template
The Depression Follow-up Visit Template is designed for primary care providers managing depression in the primary care setting. This focused template documents symptom response using standardized scales, medication effectiveness, side effects, functional improvement, and treatment plan adjustments. The template supports appropriate billing for medication management visits and includes sections for interval history since last visit, depression symptom assessment using PHQ-9 or other standardized tools, medication review with adherence and response, side effect monitoring, functional status assessment, suicide risk screening, treatment plan adjustments including medication changes, psychotherapy referral if indicated, patient education on depression and treatment, and follow-up scheduling. This template ensures comprehensive depression care in primary care, supports medication optimization, facilitates systematic symptom tracking, and improves patient outcomes through structured follow-up. Ideal for primary care practices managing depression, family medicine practices, and integrated behavioral health programs.
Template
Chief Complaint
Depression follow-up.
Interval History
Mood, sleep, appetite, energy, concentration, interest, function, adherence, side effects.
Screening
PHQ-9 score today: { } (trend: { }).
Safety
SI/HI, intent/plan, protective factors, safety plan.
Assessment & Plan
MDD — response and tolerability; med adjustments; therapy referral; follow-up timeframe.
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