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DEPARTMENT OF THE ARMY HEADQUARTERS, UNITED STATES ARMY MEDICAL COMMAND 2050 Worth Road Fort Sam Houston, Texas 78234-6010 MEDCOM Circular 40-20 4 October 2010

Expires 4 October 2012 Medical Services RE-ENGINEERING SYSTEMS OF THE PRIMARY CARE TREATMENT (OF DEPRESSION AND POST-TRAUMATIC STRESS DISORDER) IN THE MILITARY DOCUMENTATION FORM Supplementation of this regulation and establishment of command and local forms is prohibited without prior approval, unless specifically approved by the Office of the Assistant Chief of Staff for Health Policy and Services (MCHO-CL-C), 2050 Worth Road, Fort Sam Houston, TX 78234-6010. 1. History. This issue publishes a revision. 2. Purpose. The purpose of this circular is to implement revisions to U.S. Army Medical Command (MEDCOM) Form 774 (Medical Record-RESPECT-Mil Primary Care Screening) and to update policy concerning the use of this form. 3. Applicability. This policy applies to all MEDCOM personnel involved with the Re-Engineering Systems of the Primary Care Treatment (of Depression and Post-Traumatic Stress Disorder) (RESPECT-Mil) Program especially those in the areas of clinical care management, documentation, and/or program evaluation. 4. References. Required and related publications and prescribed and referenced forms are listed in appendix A. 5. Explanation of abbreviations and terms. Abbreviations used in this circular are explained in the glossary. 6. Policy. MEDCOM Form 774 (see app B) has an essential role in the RESPECT-Mil Program for both clinical care management/documentation and program evaluation purposes. MEDCOM Form 774 is used to screen Soldiers for depression and post-traumatic stress disorder (PTSD) at each primary care visit and is used by the Soldier's provider to record relevant clinical information

____________________ *This circular supersedes MEDCOM Circular 40-20, 11 September 2009.

MEDCOM Cir 40-20 regarding symptom constellation and severity, risk assessment, diagnostic impressions, treatment plan, and disposition. This form also facilitates program evaluation. Note: MEDCOM Form 774 is available electronically through usual Army Knowledge Online and Enterprise Web AEFSS forms links. a. All Soldiers in RESPECT-Mil primary care clinics will be screened at every primary care provider visit for depression and PTSD, using MEDCOM Form 774. MEDCOM 774 has six screening questions: two depression-related questions in section I and four PTSD-related questions in section II. Medics, nurses, or other clinic support staff will provide the form to Soldiers, generally as part of the previsit vital signs measurement process. Each clinic will ensure a process to verify completion of patient identifying information on the bottom of the form. b. Patients who screen positive for depression and/or PTSD will complete additional diagnostic aids (that is, the patient health questionnaire (PHQ-9) (see app C) and/or the PTSD checklist (PCL) (see app D)) provided by the medic, nurse, or other clinical staff. If the patient screens positive for depression (that is, one or more items marked "yes" on MEDCOM Form 774, section I, page 1), they are given the PHQ-9 to complete. If the patient screens positive for PTSD (that is, two or more items marked "yes" on MEDCOM Form 774, section II, page 1), they are given the PCL to complete. If a patient screens positive for both depression and PTSD, they are given both the PHQ-9 and PCL (or like questionnaire/checklist) for completion. A provider may opt to administer one or both diagnostic aids at their discretion even if the patient screens negative for the corresponding disorders. (1) The PHQ-9 is a validated diagnostic aid consisting of a functional impairment question and nine items corresponding with the Diagnostic and Statistical Manual for Mental Disorders (fourth edition) (DSM-IV-TR) diagnostic criteria for depression. As of July 2010, the PHQ-9 is within the public domain (http://www.phqscreeners.com). The PHQ-9 form can be accessed on the website www.pdhealth.mil. (2) The PCL is a validated diagnostic aid consisting of a suicidal ideation question, a functional impairment question, and 17 items that correspond with the DSM-IV diagnostic criteria for PTSD. As of July 2010, the PCL is within the public domain. The PCL can be accessed on the website www.pdhealth.mil. (3) Site champions will receive training on how to score and interpret these instruments. They, in turn, will train personnel at their site. c. In accordance with an established clinical process, support personnel, who have provided the screening form and diagnostic aids to the Soldier, will make available MEDCOM Form 774 and scored diagnostic aids (along with any other relevant information) to the provider seeing the patient.

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*MEDCOM Cir 40-20

d. The provider will record the examination results on MEDCOM Form 774, section I, page 2. If the patient screens positive for depression, PTSD, or both, the provider will then use the diagnostic aids and standard scoring guidance, any additional history or assessment, and clinical judgment to develop the working diagnosis and treatment plan. The provider will record other relevant symptom information on MEDCOM Form 774, section II, page 2 and record his/her diagnostic impressions in section III, page 2. If the patient screens negative for both depression and PTSD, RESPECT-Mil screening is complete. Diagnostic aids are not administered except per provider judgment. e. If the Soldier endorses suicide risk items on the diagnostic aids (score of 1 or above on the PHQ-9 item 9 or PCL item 19), this is noted on MEDCOM Form 774, section I, page 2. The provider must then complete the "risk assessment" section on page 2 (of MEDCOM Form 774). This section will document the provider's estimate of the level of the patient's acute suicide risk (low, intermediate, or high). f. The provider will record treatment plan information, such as prescribed medications, next follow-up appointment, and other relevant information on MEDCOM Form 774, section IV, page 2. g. The provider will record referral information using the "referral made to" options on MEDCOM Form 774, section V, page 2. For patients who are not being referred into RESPECT-Mil care facilitation, behavioral health, or another resource, the provider will document the reasons why no referral was made, using the "no-referral" options in section V (checking all that apply). Referrals to RESPECT-Mil will generally occur via electronic consultation from the provider to the RESPECT-Mil care facilitator. h. The provider will ensure that relevant information is entered into the electronic record after completing the form. Most clinics opt to have a RESPECT-Mil administrative assistant scan into AHLTA all screen-positive patients' MEDCOM Form 774. Providers will ensure that negative screens on MEDCOM Form 774 are noted in AHLTA. Many clinics will have a clinic screener routinely enter these negative screens into AHLTA on the provider's behalf. i. RESPECT-Mil administrative assistants will collect MEDCOM 774 and diagnostic aids after all encounters. The provider is responsible for ensuring these forms are securely deposited for collection according to a locally developed clinic process. j. The RESPECT-Mil administrative assistant will record relevant program evaluation information from MEDCOM Forms 774 and the diagnostic aids into the clinical care management database. MEDCOM Forms 774, from encounters

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MEDCOM Cir 40-20 involving a positive initial screen and completed diagnostic aids, will be scanned into AHLTA per clinic process (see para h, above). MEDCOM Form 774 is then dispositioned in accordance with AR 40-66 and local policy.

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*MEDCOM Cir 40-20

Appendix A References Section I Required Publications This section contains no entries. Section II Related Publications AR 40-66 Medical Record Administration and Healthcare Documentation MEDCOM Operation Order 07-34 Re-Engineering Systems of the Primary Care Treatment of Depression and PTSD in the Military-(RESPECT-Mil) MEDCOM Operation Order 10-25 Expansion of the Re-Engineering Systems of the Primary Care Treatment of Depression and PTSD in the Military-(RESPECT-Mil) Program Section III Prescribed Forms MEDCOM Form 774 Medical Record - RESPECT-Mil Primary Care Screening Section IV Referenced Forms Patient Health Questionnaire (PHQ-9) Public domain document (http://www.phqscreeners.com/) PCL (PTSD Checklist) Public domain document

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MEDCOM Cir 40-20 Appendix B MEDCOM Form 774, Medical Record-RESPECT-Mil PRIMARY CARE SCREENING The following two pages contain appendix B.

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*MEDCOM Cir 40-20

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MEDCOM Cir 40-20

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*MEDCOM Cir 40-20

Appendix C Patient Health Questionnaire (PHQ-9)

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MEDCOM Cir 40-20 Appendix D PTSD Checklist (PCL)

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*MEDCOM Cir 40-20

Glossary Section I Abbreviations DSM-IV-TR Diagnostic and Statistical Manual for Mental Disorders (fourth edition) MEDCOM United States Army Medical Command PCL PTSD checklist PHQ-9 patient health questionnaire PTSD post traumatic stress disorder RESPECT-Mil Re-Engineering Systems of the Primary Care Treatment of PTSD in the Military

Section II Terms This section contains no entries.

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MEDCOM Cir 40-20 The proponent of this publication is the Office of the Assistant Chief of Staff for Health Policy and Services (MCHO-CL-C). Users are invited to send comments and suggested improvements on DA Form 2028 (Recommended Changes to Publications and Blank Forms) to Deployment Health Clinical Center, Walter Reed Army Medical Center; 6900 Georgia Ave., NW, Building 2, Room 3E01; Washington, DC 20307-5001. FOR THE COMMANDER:

HERBERT A. COLEY Chief of Staff

HON S. PAK Colonel, MS Assistant Chief of Staff for Information Management

DISTRIBUTION: This publication is available in electronic media only. Copies can be obtained from Army Knowledge Online (AKO). SPECIAL DISTIBUTION: MCIT-ISM (Forms Mgr) (1 cy) MCIT-ISA-H (Editor) (2 cy)

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