EPDS SCREENING RECORD

Date: [Date]
Person screened: [Name or chart number, age]
Recorded by: [Name, role]

SCREEN
Stage: [Weeks pregnant, or weeks since the birth]
Screened as: [Birthing parent or partner]
Occasion: [First prenatal visit, third trimester, postpartum check, well-baby visit, or repeat]
Form: [Language; filled in alone, or read aloud word for word with an interpreter]

RESULT
EPDS total: [0 to 30]
Result band: [Depression unlikely 0 to 9, possible 10 to 12, probable 13 or more]
Item 10, self-harm: [0 to 3; if above 0, the same-day risk assessment and what it found]
Anxiety items 3 to 5: [Subtotal out of 9, if your service tracks it]
Earlier EPDS scores: [Dates and totals, or first screen]

INTERVIEW
Mood and onset: [How long, and when it began in relation to the pregnancy or birth]
Sleep, feeding, and bonding: [What the person describes beyond a newborn's usual waking]
Thoughts of harm: [To self or to the baby; whether intrusive thoughts feel unwanted]
Mania or psychosis: [Past or current signs; family history of bipolar disorder]
Other causes checked: [Thyroid, anemia, pain, substance use]
Supports and stressors: [Partner, family, money, housing, safety at home]
Assessment: [Diagnosis or screen result, and how severe]

PLAN
Support: [Peer group, home visits, practical help, protected sleep]
Therapy: [Type, and who it's referred to]
Medication: [Started, changed, or not; pregnancy or breastfeeding weighed]
Referral: [Perinatal mental health, psychiatry, social work, or none]
Safety: [Safety plan, crisis line given, who else knows]
Next EPDS: [Date or weeks from now]

Signed: [Clinician name, credentials]