Medical Data Collection Form - Depression Page 3
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4STAndards for BipoLar Excellence: STABLE Performance Measures
DATA COLLECTION FORM - DEPRESSION
Abstractor’s Initials: ___/___/___
Organization or Site Code:_______
Red #’’s correspond to algorithm data fields
Initial Assessment/Evaluation:
Date of initial mental health assessment/evaluation visit at this site relating to this episode of depression
(1)
mm_____dd_____yy______
Is there documentation about the presence of depression (see options below)?
(2)
Yes
No
If 2 Yes: Date this information is FIRST documented in chart:
(3)
mm_____dd_______yy_____
If 2 Yes: Where did you find the information about the presence of depression?
Codes 296.2x; 296.3x; 300.4 or 311 documented in body of chart, such as a pre-printed
form completed by a clinician and/or codes documented in chart notes/forms.
Diagnosis or impression documented in chart that states “depression”
Use of a screening/assessment tool for depression with a documented score or
conclusion that the patient is clinically depressed and in that this information is documented
by clinician to establish or substantiate the diagnosis
Is there documentation indicating that an assessment or screening/history was done to determine the
presence or absence of current or prior mania or hypomania episodes or behaviors?
(4)
Yes
No
BE
If 4 Yes: Date this information is FIRST documented in chart:
(5)
mm_____dd_______yy_____
If 4 Yes: Where did you find the information about this assessment or history
Clinician statement in patient record regarding inquiry regarding the presence or
absence of current or prior symptoms or behaviors associated with mania/hypomania
Use of a bipolar disorder screening tool or assessment/history tool that is documented
as considered by the clinician assigning the diagnosis
RISK OF SUICIDE:
Is there documentation concerning the risk of suicide
(6)
Yes
No
If 6 Yes: Date this information is FIRST documented in chart:
(7)
mm_____dd_______yy_____
If 6 Yes: Did you find this information in narrative notes____ ; was an assessment tool used___
ALCOHOL USE:
Is there documentation about the presence or absence of alcohol use/abuse?
(8)
Yes
No
If 8 Yes: Date this statement is FIRST documented in chart:
(9)
mm______dd______yy______
If 8 Yes: Did you find this information in narrative notes____ ; was an assessment tool used___
CHEMICAL / DRUG SUBSTANCE USE:
Is there documentation about the presence or absence of substance use/abuse?
(10)
Yes
No
If 10 Yes: Date this statement is FIRST documented in chart:
(11)
mm______dd______yy______
If 10 Yes: Did you find this information in narrative notes____; was an assessment tool used___
NLY IF
N
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2007 – STABLE Depression (Unipolar) Measures Data Collection Form
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