Medical record number
Patient name
Patient date of birth
Patient payor name
Patient payor ID
Department of PCP
Name of PCP
Date of last PCP visit
Date of last visit with PCP department
Name of pertinent psychiatrist/psychologist
Name of pertinent psychiatrist/psychologist department specialty
Date of last psychiatry/psychology visit
Date of last visit with CCD care manager
Depression/dysthymia diagnosis (yes/no)
Date of depression/dysthymia diagnosis
Diagnosis of bipolar disorder (yes/no)
Date of bipolar disorder diagnosis
Diagnosis of personality disorder (y/n)
Date of personality disorder diagnosis
Most recent PHQ-2 greater than 3 (yes/no)
Most recent PHQ-2 score if greater than 3
Most recent date PHQ-2 was greater than 3
Most recent PHQ-9 greater than 9 (yes/no)
Most recent PHQ-9 greater than 9 date
Initial PHQ-9 greater than 9 score
Initial PHQ-9 greater than 9 score
Date of last PHQ-9 administration
Antidepressant dose change or new order (yes/no)
Most recent antidepressant dose change or new order date
Most recent antidepressant dose change or new order prescribing department