Consistent PMAD screening in a busy OB or pediatric practice does not happen by having good intentions. It happens through systems. A provider who plans to screen "when it seems relevant" will screen less than half the time, because the relevant cases are often the ones who don't look distressed in the exam room.

This guide is a practical framework for building a sustainable screening workflow. It covers which staff should do what, when to screen, how to triage scores, what to document in the EHR, and what a referral pathway looks like when someone scores positive. Adapt it to your staffing model and patient volume. The goal is a system that runs consistently without requiring the provider to remember to do it.

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The Core Workflow (Seven Steps)

Step 1: Identify all prenatal and postpartum visits where screening should occur.

Define your screening schedule before anything else. Based on ACOG, USPSTF, and AAP recommendations, a minimum protocol covers:

First prenatal visit (6–12 weeks gestation)
Third trimester visit (28–32 weeks)
Postpartum visit (4–6 weeks)
2-month well-child visit (screen the mother, not the infant)
4-month well-child visit (patients with prior elevated scores or identified risk factors)
6-month well-child visit (same criteria)

Build these into your scheduling system as default screenings. If the screen must be remembered and ordered manually each time, it will be missed.

Step 2: Assign the screen to intake, not the provider encounter.

The EPDS should be completed by the patient before the provider enters the room. Build it into your intake workflow: front desk hands the patient the EPDS (or a tablet with the digital version) when she checks in, the same way vital signs are collected before the visit. This removes the time pressure from the provider encounter and ensures the score is available when the provider arrives.

For practices using digital check-in tools or patient portal forms, the EPDS can be sent to the patient in advance of the visit. Many EMR systems support this via patient portal messaging.

Step 3: Route completed scores to the provider before the encounter.

The MA or nurse who rooms the patient should record the EPDS score in the chart before the provider walks in. The provider should see the score as part of the chart review, alongside vitals, medications, and chief complaint. This positions the screening result as a clinical data point, not an afterthought.

Step 4: Apply the score triage protocol.

Define in writing how to respond to each score range. Whoever reviews the score should know what each range requires before any clinical judgment is applied.

EPDS Score	Required action
0–9	Document; no immediate action. Repeat at next scheduled screen.
10–12	Provider assessment this visit. Evaluate functional impairment, risk factors. Decide: referral now or repeat EPDS in 2–4 weeks with clear plan.
13+	Referral to perinatal mental health. Do not defer to next visit.
Item 10 > 0	Direct follow-up before patient leaves. Assess for plan, intent, means. See safety protocol.

Post this on the wall in the nursing station or build it into your EHR workflow so it does not require memorization.

Step 5: The provider has the referral conversation.

Score triage can be handled by an MA or nurse. The referral conversation should not be. Patients with elevated scores often need clinical context and human connection before they will agree to a referral. They need to hear from their provider that what they're experiencing is real, that it's treatable, and that the referral is a clinical recommendation, not an administrative action.

Two to three minutes is enough. You do not need to conduct a therapy session. You need to say: "Your score today tells me you're having a harder time than a lot of people realize. I want you to talk to someone who specifically works with new mothers. This is who I send my patients to."

For specific language on managing patient reluctance, see when and how to refer postpartum patients for mental health support.

Step 6: Submit the referral before the patient leaves.

A referral that the provider intends to submit and never does is not a referral. Build the submission into the workflow of the encounter: if a referral is indicated, either the provider or an MA submits it before the patient checks out.

Phoenix Health's referral form is accessible online at joinphoenixhealth.com/referrals/ and takes approximately two minutes. It captures the patient's name, contact, insurance, and a brief clinical note. We contact the patient within one business day and handle intake, insurance verification, and therapist matching.

If your practice prefers a warm handoff (patient speaks to a care coordinator before leaving the office), call 818-446-9627 and we can facilitate that in most cases during business hours.

Step 7: Document and close the loop.

Document in the EHR: screening tool used, score, clinical assessment, decision made, and referral submitted (with date and destination). Set a follow-up flag if you are monitoring a patient at the 10–12 range rather than referring immediately. The flag should trigger a repeat EPDS at the next visit and a check on whether a referred patient has connected with mental health care.

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Staff Roles and Responsibilities

Role	Responsibilities
Front desk / check-in	Administer EPDS at intake; collect completed form
MA / nurse	Record score in chart; flag scores ≥10 for provider review before encounter
Provider (OB, midwife, peds)	Review score; conduct clinical assessment for elevated scores; have referral conversation; submit referral or direct MA to do so
Social worker (if embedded)	Warm handoff for score-positive patients; facilitate referral; provide brief emotional support and psychoeducation in same visit

Practices without embedded social workers can still run an effective workflow. The key is that the provider does not have to remember to do every step: MA handles the flag, provider handles the conversation, and either one handles the submission.

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EHR Documentation

Consistent documentation serves multiple functions: it creates a clinical record, supports billing, and allows you to track your screening program over time.

Minimum documentation for each screening visit:

Screening tool used: EPDS (note if EPDS + GAD-7)
Score recorded
Clinical response: "Patient scored 14 on EPDS. Clinical assessment completed this visit. Referral submitted to Phoenix Health perinatal mental health, [date]. Follow-up at next scheduled visit."

ICD-10 codes by scenario:

Scenario	Code
Screening encounter, no diagnosis confirmed	Z13.32
Confirmed postnatal depression	F53.0
Major depressive episode, mild	F32.0
Major depressive episode, moderate	F32.1
Major depressive episode, severe without psychotic features	F32.2
Generalized anxiety disorder	F41.1
Panic disorder	F41.0
OCD (intrusive thoughts, postpartum)	F42.2
Postpartum psychosis	F53.1
Referral submitted, patient not yet evaluated	Z13.32 + referral documentation
Patient declined screening	Document in note; no Z13.32

Do not apply an F-code (F53.0, F32.x) based on a screening score alone. These codes indicate a confirmed diagnosis. Use Z13.32 for the screening encounter, and add the appropriate diagnostic code only after clinical assessment confirms it.

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Selecting and Implementing a Screening Tool

For practices that have not yet standardized on a tool, the EPDS is the recommended instrument for first-line perinatal screening. It was validated specifically for perinatal populations and avoids the somatic items (sleep, fatigue, appetite) that inflate false positives in postpartum patients using the PHQ-9.

For a full comparison of EPDS, PHQ-9, and GAD-7 cutoff scores, sensitivity data, and timing recommendations, see EPDS vs. PHQ-9 vs. GAD-7: Choosing a PMAD Screening Tool for OB and Midwifery Practices.

Paper vs. digital: Both work. Digital administration (tablet, patient portal) reduces transcription errors and can pre-populate scores into the EHR. Paper is more reliable in practices where digital workflows are not yet fully integrated. Choose the format your staff will actually use consistently over the format that seems more sophisticated.

Training: Staff administering the EPDS should understand what it is, why it's being collected, and what to do if a patient asks about it. A ten-minute training covering the tool's purpose and the practice's triage protocol is sufficient. Staff do not need clinical training to administer the screen. They need to know that it's a standard part of every appointment, like vital signs, and that the provider handles everything from there.

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Tracking Your Screening Program

A workflow without any data review will drift over time. Once per quarter, pull a simple report:

How many eligible patients were screened? (Target: ≥80%)
Of those screened, how many scored ≥10? How many ≥13?
Of those scoring ≥13, how many received a referral?
Of those referred, how many connected with care? (Requires follow-up data or report from referral destination)

This does not need to be a formal quality improvement project. A ten-minute review of these numbers shows you where the workflow is working and where it is not. Low screening rates usually indicate a breakdown in the intake step. Low referral rates for high scores usually indicate a gap in the referral conversation or submission step.

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Common Implementation Problems

"We forget to give the screen at intake." This is an intake systems problem, not a memory problem. The EPDS should be on a checklist that is executed at every applicable visit type, not remembered by the person at the front desk. Build it into the appointment type in your scheduling system so that check-in prompts it automatically.

"Patients don't complete the screen before the visit." If you are sending it via patient portal in advance, completion rates vary. Have a paper version at check-in as a fallback. A screen completed in the waiting room is better than one not completed at all.

"The provider doesn't have time to address a positive score." This is the hardest one, and it is real. In a 15-minute OB visit, a positive EPDS score is a scheduling problem if there is no protocol. Two approaches: (1) build in a brief add-on at the visit for score review ("if screen is positive, add 5 minutes to the appointment"), or (2) ensure the MA or social worker handles the referral logistics so the provider only needs to have the two-minute conversation, not manage the submission.

"We refer patients but they don't follow up." Warm referrals (provider or staff facilitates direct contact before the patient leaves) have higher uptake than paper referrals. If your referral pathway involves handing the patient a phone number, expect low uptake. If it involves submitting the referral on her behalf while she is in the office, uptake improves substantially.

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FAQ

Which Staff Member Should Administer the EPDS

The EPDS can be administered by front desk staff, MAs, or nurses as a check-in step before the provider encounter. The provider reviews the score before or during the visit. The referral conversation should come from the provider because clinical context and follow-up questions matter. Practices with embedded social workers can route score-positives directly to the social worker for a warm handoff.

How to Document PMAD Screening in the EHR

Use Z13.32 (encounter for screening for maternal depression) as the primary encounter code when screening is the purpose. Document the screening tool used (EPDS), the score, and the clinical response. If a diagnosis is confirmed, add the appropriate F-code. Do not use an F-code based on a screening score alone without a clinical assessment.

Can We Bill for PMAD Screening at a Well-Child Visit

Yes. Screening for maternal depression at well-child visits is supported by AAP policy and is billable. The AAP recommends screening mothers at the 1-, 2-, 4-, and 6-month well-child visits. Use Z13.32 for the screening encounter. Some payers require a separate encounter code or modifier; check your specific payer contracts.

What to Do When a Patient Declines Screening

Document that screening was offered and declined. Note the reason if given. Declining screening is not the same as declining treatment. Re-offering at the next visit is appropriate. You cannot force a screen, but keeping the door open ("We do this for everyone and we'll ask again at your next visit") maintains the relationship and the option.

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Ready to evaluate a perinatal mental health referral partner? For guidance on what to look for, including PMH-C certification, wait times, and collaborative care protocols, see choosing a perinatal mental health referral partner for OB practices.

Ready to refer now? Submit a referral for an individual patient, or contact our clinical partnerships team to discuss building a standing arrangement for your practice.

How to Build a Postpartum Depression Screening Workflow in Your OB Practice