chart-review-cp-depression

name	chart-review-cp-depression
description	Identify evidence of depression from a patient's post-index clinical notes: explicit diagnosis, depressive symptoms, antidepressant use, psychiatry referral, and PHQ-9 severity. Tier and final Depression/No Depression decision are computed. Evidence-cited. Triggers on: depression, PHQ-9, depressive disorder, MDD, antidepressant.

Procedure

This is a notes-only phenotype task for a GLP-1 / obesity-T2D cohort. You answer five leaf fields directly:

• high_confidence_diagnosis — yes / no / no_info.
• depressive_symptoms — yes / no / no_info.
• antidepressants — yes / no / indication_not_verified / no_info.
• psychiatry_referral — yes / no / no_info.
• phq9_severity_band — minimal / mild / moderate / moderately_severe / severe / not_documented.

study1_tier, phq9_threshold_met, and final_decision are computed fields — do NOT answer them directly.

This is a two-pass procedure. Do not read a note and immediately commit a field answer from it — that is exactly the failure mode this task is prone to (this chart type has the same diagnosis and PHQ-9 score repeated across many visits; answering from the first note you read will silently drop the other five, ten notes that also support it).

Pass 1 — per-note scan (build the evidence index)

1. Call list_structured_data FIRST. Its response includes index_date for this patient — record it. Then call list_notes, which returns each note's date. Only notes with a date strictly AFTER index_date are in scope — a note dated exactly ON the index date is OUT of scope. Drop every out-of-scope note from your working set now, before Pass 1 starts; do not open or cite them.
2. list_criteria + read_criteria([...]) for all five leaf fields, before reading any notes, so you know what to look for.
3. Go through the in-scope notes per your session's search mode (smart-search: search_notes for high-signal terms, then read_note/read_notes on matches; comprehensive: read every in-scope note in full, one at a time, in date order).
4. For EVERY note you read, before moving to the next note: scan it against all five fields and call select_evidence(evidence, field_id, category, rationale) once for each passage in that note relevant to each field it bears on. One note commonly informs more than one field (e.g. a visit note with both a diagnosis line and a PHQ-9 score pins two select_evidence calls, one per field_id) — pin all of them before advancing. Do this even for a note you're fairly sure won't change the final answer; the index has to be complete, not just sufficient. Skipping this step for a note is equivalent to not having read it.
5. You must reach the last in-scope note before starting Pass 2. Stopping early because you already have "enough" evidence for a field is the discipline failure this procedure exists to prevent.

Pass 2 — synthesize (commit the five leaf fields)

6. Call get_review_state to retrieve everything you pinned in Pass 1.

7. For each of the five leaf fields, gather every pinned item with that field_id and commit ONE answer via set_field_assessment(field_id, answer, confidence, evidence, rationale). The answer MUST be one of the field's enum values.

   Multi-citation rule (mandatory): evidence is an ARRAY. Copy in EVERY distinct note's pinned item that supports the committed answer — if six separate visits each document the same diagnosis, or two notes each mention a different depressive symptom, all of them go in as separate evidence items. A single-item evidence array is only correct when Pass 1 pinned exactly one supporting item for that field — check your Pass-1 index before assuming that. The rationale should synthesize across all cited spans and name any tension between notes (e.g. a diagnosis mentioned in five visits but denied in a sixth).

   Span discipline — cite the SMALLEST span that supports each point:

   • Quote the single sentence/phrase that justifies it (well under ~300 chars) per evidence item. Use find_quote_offsets to get exact offsets so the faithfulness gate passes.
   • Do NOT cite a whole note as one block.
   • Every cited span must be affirmative — never cite a negated sentence ("denies depression", "no suicidal ideation") to support a positive answer; a negation supports no.
   • For no / no_info / not_documented: always cite at least one short span — the section(s) you checked where the info would appear if present.

Decision rules (apply across all leaf fields)

• Priority sections: HPI, Assessment/Plan (incl. Problem List), Social History, Medications/Home Medications. Exclude: generic Discharge Instructions boilerplate ("Call your doctor if you have suicidal feelings") and patient-instruction templates — these are not patient evidence.

• Negation: if a depression term is preceded within ~80 characters by "no", "not", "denies", "denied", "denying", "without", "negative", "absence of", "absent", "never" — it is negated. Do not count it.

• Non-psychiatric "depression": EKG/cardiology ("ST depression", "ST elevation or depression"), cardiac function ("depression of systolic function"), orthopedic/anatomical ("depression of the lateral tibial plateau", "depressed fracture") are never evidence for high_confidence_diagnosis.

• Antidepressant alternate indications — check the note for a documented non-depression reason before counting a drug as positive:

  Drug	Non-depression indications to check for
  Duloxetine (Cymbalta)	Fibromyalgia, neuropathic/diabetic pain, musculoskeletal pain
  Bupropion (Wellbutrin)	Smoking cessation, ADHD, weight management
  Trazodone (Desyrel)	Insomnia, sleep disturbance
  Amitriptyline (Elavil)	Neuropathic pain, migraine prophylaxis, headache
  Nortriptyline (Pamelor)	Neuropathic pain, migraine prophylaxis, ENT dizziness
  Escitalopram (Lexapro)	GAD, PPPD, panic disorder
  Sertraline (Zoloft)	Anxiety, OCD, PTSD

  If a non-depression indication IS documented → no. If the drug is present but no indication is documented at all → indication_not_verified (still meaningful evidence, just unverified — do not silently drop it).

• GLP-1 confound: if the only "symptoms" present are weight loss, poor appetite, or fatigue, AND the note documents concurrent GLP-1 therapy, treat these as a likely medication effect rather than depressive symptoms — do not answer depressive_symptoms=yes on these alone. Note the ambiguity in rationale. A genuine depressive-symptom mention (mood, anhedonia, hopelessness, guilt, SI, concentration) is unaffected by this caution.

• PHQ-9 extraction:

  • You must scan every in-scope note for a PHQ-9 mention before committing this field — the highest score is frequently NOT in the first note you find one in. Cite every distinct post-index PHQ-9 occurrence you found as a separate evidence item (per the multi-citation rule above), not just the one that set the band.
  • Use the highest post-index PHQ-9 total score found anywhere in the chart to pick the band: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately_severe, 20–27 severe.
  • "PHQ 18/27" → total 18 (27-point base confirms PHQ-9).
  • Multiple PHQ-9 mentions in the same note → use the last occurrence in that note.
  • A carried-forward score cited on a later date is NOT a new assessment — attribute it to its original date, and don't let it override a higher, more recent, genuinely new score.
  • Qualitative wording alone ("mildly depressed") without a number → do NOT assign a band from it; keep looking for a real PHQ-9 score.
  • PHQ-2 (max 6 points) is NOT PHQ-9 — never substitute it in.
  • If PHQ-9 and GAD-7 both appear in the same note, verify carefully which number belongs to PHQ-9.
  • No PHQ-9 documented anywhere post-index → not_documented.
  • Record the actual numeric score(s) you found in rationale even though the committed answer is the band.

• Confidence: high = explicit, unambiguous documentation (diagnosis term in Assessment/Plan, a clearly-dated PHQ-9 number); medium = inferred/pattern-based (e.g. antidepressant with no indication documented, symptom cluster without explicit diagnosis); low = ambiguous or borderline — prefer no_info/not_documented over a low-confidence guess.

8. Confirm all FIVE leaf fields (high_confidence_diagnosis, depressive_symptoms, antidepressants, psychiatry_referral, phq9_severity_band) have a set_field_assessment — every leaf must have a value (use no_info/not_documented if genuinely absent, but only after Pass 1 covered every in-scope note). Do NOT commit study1_tier, phq9_threshold_met, or final_decision — they are derived automatically. Do NOT call set_review_status. Once the five leaves are committed, emit a one-line summary and stop.