Depression/Mental Health Flow Sheet

Provisional Dx: (Revise PRN)______

Intervention:watch/waitmedicationtherapy (circle all that apply)

Date,
Provider Initials
& Type of Visit / PHQ scores & Tx phase
repeat PHQ at least q 4-6 weeks
or sooner prn / Medication flow
(see med sheet)
consider med ∆ if:
- no respone @ 6 wks or
- partial response @ 12 wks
and/or consider adding counseling / Psychotherapy flow
consider ∆ to meds or add meds if:
- no response @ 6 wks
- partial response @ 12
wks / Self-Management & Educational Materials / Brief Visit Notes
- When is next f/u visit?
- Type of visit
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______
Date______
Provider______
Office visit
depression
other reason
Phone call / Score:______
Watch & wait
Acute phase tx
Cont. phase tx
Maint. phase tx / New Rx ______
∆ dosage ______
DC’d ______
No ∆ / CMHC Tx
New referral
Current Pt
Release signed
PCBH Tx
New referral
Current Pt / Depression & Tx Info
Self-care Action Plan
Anti-dep Rx educ form
Other literature:
specify:______/ Next visit due: ______
Office visit
Phone contact
Notes:______

Name:______

DOB:______ID #: ______

Gender: M F

The 3 phases of depression treatment:

acute phase: aims at minimizing depressive symptoms – typically first 3-4 months of tx

continuation phase: tries to prevent return of symptoms in current episode – months 4-12

maintenance phase: tries to prevent return of symptoms within 2 years – months 12 - 24

Continuation & Maintenance phases: repeat PHQ q 4-6 months / Continuation & Maintenance phases: keep same dose of antidepressant Rx for at least 9 months after return to well state / “CMHC” = Community Mental Health Center
“PCBH” = Primary Care Behavioral Health staff

FORMNAME - #### Rev 10/12/18