01 / ADAPTABLE OUTLINE
What to document
Symptoms & function
Duration, depressed mood, anhedonia, sleep, energy, concentration, appetite, function, prior episodes, previous treatments, substances, and medical contributors.
Mental status & safety
Observed appearance, behavior, speech, mood, affect, thought process, perception, cognition, and a direct suicide assessment; assess past mania or hypomania.
Assessment & PHQ-9
Record all responses, total, severity band, item 9, functional impact, differential, and the clinical interview supporting the assessment.
Shared plan & follow-up
Psychotherapy and medication choices, dose and monitoring if prescribed, adverse effects, safety plan when indicated, and a specific reassessment interval.
02 / WORKED EXAMPLE
Depression evaluation with a moderate PHQ-9 score
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
HPI
A 45-year-old patient describes two months of low mood and reduced interest, with impaired concentration and sleep. Work and home tasks are somewhat difficult. The interview supports a major depressive episode. No history of mania or hypomania is elicited; medication, substance, and medical contributors were reviewed.
Mental status & screening
The patient is cooperative with normal-rate speech, depressed mood, congruent affect, and linear thought process. No psychotic symptoms are elicited. PHQ-9 is 10/27, moderate symptom range; item 9 is 0. Direct inquiry identifies no current suicidal thoughts, intent, or plan. Safety assessment is documented separately from the score.
Assessment & plan
Major depressive disorder assessed clinically. Psychotherapy and medication options were discussed. Following individualized safety and interaction review, the patient elects sertraline 50 mg orally once daily and a psychotherapy referral. Discussed adverse effects, emerging agitation or manic symptoms, and clinical worsening. Reassess symptoms, tolerability, and safety in two weeks, sooner for concerns. Emergency help is advised for imminent danger or inability to stay safe.
A common documentation question
Can a PHQ-9 of zero rule out suicide risk?
No. Screening responses do not replace direct assessment when there is a concern. A positive item 9 response needs prompt direct follow-up even if the total is low or the questionnaire is incomplete.
03 / CLINICAL REASONING
Differential & testing considerations
Examples to consider—not diagnoses to automatically include in a note.
Differential
- Major depressive disorder
- Bipolar depression
- Adjustment, grief, or anxiety-related symptoms
- Medication, substance, sleep, or medical contributors
Testing & assessment
- PHQ-9 quantifies symptoms over the previous two weeks; complete the clinical interview and functional assessment.
- Order medical testing only when history or examination suggests a contributor.
- Assess safety directly regardless of score, especially for any positive item 9 response.
04 / TREATMENT & DOSAGE REFERENCES
Make the plan specific.
Selected adult references, not a complete protocol or individualized prescription. Check the indication, formulation, allergies, pregnancy, renal/hepatic function, interactions, and current local guidance. Sources checked September 10, 2026.
Sertraline — adult major depressive disorder reference
Label starting dose: 50 mg orally daily. If needed and tolerated, increase by 25–50 mg no more often than weekly; maximum 200 mg/day.
Choose treatment with the patient and monitor symptoms, tolerability, and safety. This dose reference does not apply unchanged to every indication or patient.
Safety review: Screen for bipolar disorder. Review suicidality, MAOIs and other interactions, serotonin syndrome, bleeding and hyponatremia risk. Mild hepatic impairment requires half dosing; moderate/severe hepatic impairment is not recommended in the label.
DailyMed: sertraline prescribing information ↗TRY AN INTERACTIVE EXAMPLE
PHQ-9, from responses to documentation.
Select inputs, see the score, and preview the documentation. Missing answers stay incomplete.