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Primary Care — Depression Follow-up Template

Primary Care Family Medicine Updated: 11/7/2025

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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