Depression Documentation Guidelines

Core Documentation Components

The American Academy of Pediatrics recommends documenting PHQ-9 scores with specific cutoffs: none/mild (1-7), moderate (8-14), moderate to severe (15-19), or severe (20-27) symptomatology in patients with depression 1, 3
The American Psychiatric Association suggests recording 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) in patients with depression 1, 4
The National Institute of Mental Health recommends documenting 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 in patients with depression 1, 3, 5
The American Academy of Family Physicians suggests including whether symptoms cause functional impairment in home, peer, and school/work settings in patients with depression 6, 7

The American College of Physicians recommends documenting pertinent history and specific risk factors, including prior mood disorder with or without prior treatment, comorbid mood and/or anxiety disorders, presence of other chronic illnesses, recurrent, advanced, or progressive disease, social factors, unemployment, and lower education in patients with depression 1

The American Academy of Pediatrics recommends that every depression assessment must include suicide risk documentation, including presence or absence of suicidal ideation, behaviors, and prior attempts, availability of lethal means, adequacy of adult supervision and support, and emergency contact information and safety plan details in patients with depression 1, 6, 7

The American Psychiatric Association suggests referencing DSM-5 or ICD-10 diagnostic criteria when documenting the diagnosis of depression 8, 9
The National Institute of Mental Health recommends documenting 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 in patients with depression 5

The American Academy of Pediatrics recommends documenting specific treatment goals in key areas of functioning: home, peer, and school/work settings in patients with depression 6, 7
The American College of Physicians suggests recording patient and family education provided about depression causes, symptoms, impairments, and expected treatment outcomes in patients with depression 6, 7
The American Academy of Family Physicians recommends documenting discussion of confidentiality limits, including need to involve parents or authorities when risk of harm exists in patients with depression 6, 7
The National Institute of Mental Health suggests recording treatment choice and rationale: psychotherapy, pharmacotherapy, or combined treatment in patients with depression 2

The American College of Physicians recommends regular assessment using standardized instruments, including PHQ-9 or MADRS, at pretreatment, 4 weeks, 8 weeks, and end of treatment in patients with depression 2, 10
The American Academy of Pediatrics suggests including patient-reported outcomes, such as QIDS-SR, alongside clinician-administered scales in patients with depression 10
The American Academy of Family Physicians recommends recording assessment of symptom relief, side effects, adverse events, and patient satisfaction at 4 and 8 weeks for pharmacologic treatment in patients with depression 1, 2

The American College of Physicians recommends documenting depression screening and assessment at initial diagnosis/start of treatment, regular intervals during treatment, 3, 6, and 12 months after treatment, diagnosis of recurrence or progression, when approaching death, and during times of personal transition or reappraisal in patients with depression 1, 3, 4