Professional Documents
Culture Documents
DEPRESSIon
PAtIEnt CARE FloW SHEEt
NAME OF PATIENT BIRTHDATE
PHN COMORBID CONDITIONS
DIAGNOSIS
HltH-BCMA 6004 (Rev. 2007)
A
C
U
T
E
T
R
E
A
T
M
E
N
T
(
8
-
1
6
W
E
E
K
S
)
DAtE (YY/MM/DD)
TELEPHONE NUMBER
Medication/Dose
Referral made
Assessed
Referral made
Ongoing
Q2 Result
W (weekly)
B (Bi-weekly)
O (other)
Y (cont. meds 2 yrs)
N (cont. meds 6 mos)
PSYCHOTHERAPY
(CBT/IPT/PST
ANTIDEPRESSANTS
PSYCHIATRY
SUICIDE RISK
PHQ-9
SELF-MANAGEMENT
(education/community,
resources, social
supports)
ER VISIT OR
HOSPITALIZATION
PLANNED FOLLOW-UP
RISK FACTORS FOR
RELAPSE
ANTIDEPRESSANTS
PSYCHIATRY
PHQ-9
SELF-MANAGEMENT
(incl discussion of
relapse prevention)
PLANNED FOLLOW-UP
EMPLOYMENT STATUS
Employed Unemployed
Student Retired
Homemaker
Mania/Hypomania Past suicide attempt Anxiety disorder
Alcohol/drugs
Other: _______________________
Single episode Recurrent episode Chronic episode
MEDICAL:
Respiratory Neurological disorder Cancer Hypertension Other endocrine
Diabetes Kidney disease Arthritis Heart disease Liver disease
Other: _______________________
Ongoing
Side effects monitored
PSYCHIATRIC:
Management plan
documented
Follow-up visit
(within 7 days)
M
A
I
N
T
E
N
A
N
C
E
T
R
E
A
T
M
E
N
T
(
6
M
O
S
-
2
Y
R
S
O
R
L
O
N
G
E
R
)
Medication/Dose
Side effects monitored
Referral made
Ongoing
Goals set and/or
reviewed
Q1 Score
Goals set and/or
reviewed
M (monthly)
6 (6 mos)
O (other)
Tapering Plan
(discont symp discussed)
Q1 Score
Q2 Result
(Remission: <5)
(Remission: <5)
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
Guidelines &
Protocols
Advisory
Committee