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Patient details view

A chart header dense enough to work from, a chronology that states what it is a view of, and a record section that is present and withheld rather than quietly deleted.

Patients Okonkwo, Rachel

Okonkwo, Rachel

In treatmentRisk review due 4h
MRN 40-118-227DOB 1991-03-14 · 35yShe/her
Episode
Ep-2026-0118 · week 9 of 16
Primary clinician
E. Lake, LCSW
Modality
Telehealth · weekly
Consent on file
Treatment · 12 Feb 2026
Allergies
Sertraline — rash · 1 more

Measures

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PHQ-9Not on track
16/ 27
taken 12 Augdue 19 Aug
GAD-7Responding
9/ 21
taken 12 Augdue 19 Aug
C-SSRSPositive
+/
screened 12 Augf/u in 4h

Scale position is drawn against the instrument’s own range, not a percentage. Sparkline is the last six administrations.

Treatment response

Above expected band since S5
271890moderate · 10remission · 5expected for an intake of 18intakeS4S8S10

The reading a delta arrow cannot give you: the score fell 2 points, and that is still failure.

Problem list

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Major depressive disorder, recurrentactiveF33.1 · since Feb 2026 · focus of treatment
Generalised anxiety disorderimprovingF41.1 · since Feb 2026
InsomniasecondaryG47.00 · since Mar 2026

Medications

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Sertraline 100 mgactiveoral, daily · since 12 Feb · unchanged at review
Trazodone 50 mgneworal, at night · started 05 Aug
Zolpidem 5 mgstoppedoral · discontinued 05 Aug

Chronology

90 days · 3 sources · 2 filters
12 Aug
PHQ-9 administered — 16
Third consecutive administration without movement
12 Aug
C-SSRS positive — ideation, no plan
Safety plan updated same session
12 Aug
Individual therapy, 50 min
E. Lake · note unsigned
05 Aug
Safety plan reviewed
Previous review 41 days earlier
29 Jul
Medication review
Sertraline continued at 100 mg

This view is partial. Two sources are filtered out and one is withheld. The chronology says so rather than presenting itself as the record.

Record sections

Ideation reported without plan or intent at the 12 Aug session. Safety plan reviewed and updated the same day. Follow-up contact due within 24 hours of a positive screen under clinic policy.

This section exists and is withheld. Substance-use records are governed by 42 CFR Part 2 and require a separate consent on file. The row is shown rather than removed, because deleting it would claim the record is complete.

Referred by primary care in February for low mood and sleep disruption of roughly six months duration.

Next contact

Thu 14 Aug
14:00 · Telehealth · 50 min
Risk follow-up is due before this. 4h 12m remaining.

Care team

E. Lake, LCSW
Primary clinician · Northwind
On call
J. Tashpulatov, MD
Prescriber · Northwind
M. Delacroix
Care coordinator

Engagement

Sessions attended11 of 13
Cadence heldweekly

Engagement is intact. That is what makes the flat PHQ-9 a treatment question rather than an attendance one.

Details

Contactmobile
Insuranceverified
Emergency contact1 listed
PharmacyRiverside

Upcoming orders

No orders scheduled.
Nothing is pending — this is an empty state, not a loading one.

What to look at: Two things a conventional chart header cannot say: that this view of the record is partial, and that a substance-use section exists but is governed by a different federal rule than the chart around it. The instrument cards carry a scale, a trajectory and a next-due date, where a conventional snapshot shows a score and a delta arrow.