DEPRESSION

Depression Assessment Chief Complaint: The patient reports persistent feelings of sadness and hopelessness for the past three months. History of Present Illness: Duration of symptoms: 3 months Severity: Moderate Associated symptoms: Fatigue, difficulty concentrating, and changes in appetite Precipitating factors: Recent job loss Previous episodes: None reported Impact on daily functioning: Difficulty maintaining daily responsibilities and social interactions Past Psychiatric History: Previous diagnoses: None Hospitalizations: None Suicide attempts: None Medications: Current psychiatric medications: Sertraline 50mg daily Past psychiatric medications and response: None Family History: Mental health disorders in first-degree relatives: Mother with a history of depression Social History: Occupation: Unemployed Living situation: Lives alone Substance use: Occasional alcohol use Support system: Limited, primarily friends Mental Status Examination: Appearance: Well-groomed Behavior: Cooperative Speech: Normal rate and rhythm Mood and affect: Depressed mood, restricted affect Thought process and content: Logical, no delusions Cognition: Alert and oriented Insight and judgment: Fair PHQ-9 Score: PHQ-9 score: 15 Risk Assessment: Suicidal ideation: Denies Homicidal ideation: Denies Self-harm behaviors: None Diagnosis: Major Depressive Disorder, moderate Treatment Plan: Psychotherapy: Cognitive Behavioral Therapy, weekly Medication management: Continue Sertraline 50mg daily Lifestyle modifications: Encourage regular exercise and healthy diet Follow-up appointment: In 4 weeks Patient Education: Information provided about depression: Discussed symptoms and treatment options Treatment options discussed: Medication and therapy Safety plan if applicable: Discussed emergency contacts and crisis hotline Referrals: Referred to a psychologist for therapy Disclaimer: Billing codes are only intended as a guide. It is the healthcare provider's responsibility to ensure their appropriateness and accuracy for each consultation.