How to Score and Document a PHQ-9 (Nursing Guide)

Why This Matters

Regulatory bodies: U.S. Preventive Services Task Force (USPSTF), American Academy of Family Physicians (AAFP), American Psychiatric Association (APA), Joint Commission - National Patient Safety Goal 15.01.01 (Suicide Risk Reduction), 988 Suicide and Crisis Lifeline (federally designated)

1. The PHQ-9: validity of a brief depression severity measure — Kroenke K, Spitzer RL, Williams JB. J Gen Intern Med. 2001;16(9):606-613 (2001)
2. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Final Recommendation — U.S. Preventive Services Task Force, June 20, 2023 (Grade B for adult depression screening) (2023)
3. Depression Screening: A Practical Strategy — Maurer DM, Raymond TJ, Davis BN. Am Fam Physician. 2018;98(8):508-515 (2018)
4. 988 Suicide and Crisis Lifeline (federally designated) — SAMHSA / Vibrant Emotional Health, 988 Suicide and Crisis Lifeline (2024)
5. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition — American Psychiatric Association, October 2010 (2010)
6. R3 Report Issue 18: National Patient Safety Goal for Suicide Prevention (NPSG 15.01.01) — The Joint Commission, November 2018 (effective July 1, 2019) (2018)

What the PHQ-9 Measures and Where It Is Used

The 9 Items, Walked Top Down

The PHQ-9 covers the nine DSM-aligned domains of major depressive disorder. Each item receives a rating from 0 to 3 based on the past 2 weeks: 0 (not at all), 1 (several days), 2 (more than half the days), 3 (nearly every day).

Scoring, Severity Bands, and the Functional Impairment Item

Item 9: The Suicidality Flag and What It Triggers

PHQ-2, PHQ-9, GAD-7: How the Screens Layer in Primary Care

PHQ-9 Documentation in NurseChartingPro

Common Mistakes

Case Example

1000 PHQ-9 Screening:

PHQ-9 total: 14 (moderate severity band).

Component scores (each 0-3, recall 2 weeks):
- Item 1 (anhedonia): 2 (more than half the days)
- Item 2 (depressed mood): 2 (more than half the days)
- Item 3 (sleep): 2 (more than half the days)
- Item 4 (fatigue): 2 (more than half the days)
- Item 5 (appetite): 1 (several days)
- Item 6 (worthlessness/guilt): 2 (more than half the days)
- Item 7 (concentration): 1 (several days)
- Item 8 (psychomotor): 1 (several days)
- Item 9 (thoughts of self-harm): 1 (several days) - POSITIVE

Functional impairment: "Very difficult" to do work, take care of things at home, or get along with other people.

Item 9 follow-up:
Bedside open-ended question: "Tell me more about that." Patient stated, "Sometimes I think my family would be better off without me, especially since the diagnosis. I have not thought about how I would do it." Denies current plan, denies access to means at home (no firearms, medications stored in locked cabinet per spouse). Spouse aware of recent mood changes and named as designated support contact. Patient agreed to a safety plan: notify spouse or call 988 if thoughts intensify; spouse to remove any prescription opioid bottles when patient is discharged.

Action taken:
- Provider notified via secure message at 1015.
- Behavioral health consult ordered, expected within 24 hours.
- Sitter not indicated at this time; environmental precautions reviewed (sharps secured, medication double locked).
- Patient education at the bedside: reviewed coping skills and stress-relief techniques (paced breathing, grounding, brief activity scheduling) with patient and spouse; reinforced safety plan and reasons-for-living list patient identified (children, recovery from surgery).
- Discharge resources provided in writing: 988 Suicide and Crisis Lifeline (call or text 988, chat at 988lifeline.org), outpatient mental health follow-up, and primary-care follow-up.
- Reassess PHQ-9 component item 9 (for suicidality) at 1400 and at every shift handoff until consult complete.

Pro Tips

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  Read Each Item Verbatim: Read every PHQ-9 item exactly as it appears on the screen. Do not paraphrase, summarize, or soften the wording (especially on item 9). Reading items in your own words changes their meaning and breaks the validation. Verbatim reading is also what keeps scores comparable across providers, clinicians, and nurses on the same patient.
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  Read Item 9 First, Then the Total: Most nurses read from top to bottom: total, severity, and item 9 last. Reverse this habit. Item 9 carries clinical weight independent of the total. Reading it first indicates whether the chart entry requires a safety paragraph before mapping the severity band. Use the total for trend analysis; rely on item 9 for the next 30 minutes.
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  What Makes the Score Valid: the 2-Week Recall Window: Read the recall window out loud to the patient: "Over the past 2 weeks, how often have you been bothered by the following problems?" The 2-week window is what makes the score map to DSM major-depression criteria. Patients who answer for "today" or "the past few months" produce a score that does not match the validated thresholds, and the score has to be readministered with the correct recall instructions.
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  A Declined Item Is Not a Zero: When a patient declines an item (especially item 9), do not score it as 0 to make the math work. A declined item renders the total uncalculable and should be documented as a partial PHQ-9. Specifically, a declined item 9 is a significant safety signal; document the decline, note the follow-up, and let institutional policy determine whether to treat it as positive (most do).
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  Pair PHQ-9 With GAD-7 When Anxiety Is in the Picture: Depression and anxiety are highly comorbid, and PHQ-9 alone misses the anxiety dimension. If the patient endorses worry, irritability, or restlessness during the bedside follow-up, the next administration to add is the GAD-7. The Kroenke 2009 PHQ-4 (combining PHQ-2 and GAD-2) is the ultra-brief equivalent if your unit uses entry-level screens.
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  Differentiate Score from Diagnosis in Every Chart Entry: Chart "PHQ-9 score 18, moderately severe band, score consistent with possible major depression, clinical interview pending." Do not chart "patient has major depression." The score does not establish the diagnosis. The clinical interview that follows (performed by a provider or clinician, not the nurse) does. Keeping that distinction in your chart entry protects the next provider from having to walk back an overreach.

Step by Step

1. Frame the 2-week recall window: Read the recall instructions aloud: "Over the past 2 weeks, how often have you been bothered by the following problems?" The 2-week window is what makes the score map to validated thresholds. Patients answering for "today" or "this month" produce a score that does not match the published interpretation.
2. Score each item 0 to 3: Walk through items 1 to 9 with the patient. Score each item as follows: 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day). Document the patient's response verbatim when uncertain. Let the score reflect the patient's words, not your interpretation.
3. Sum the score and identify the severity band: Add the 9 item scores to get a total from 0 to 27. Map the total: 0-4 minimal, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe. A score of 10 or higher is the most common screening trigger.
4. Document item 9 separately: Any item 9 above 0 requires documenting a suicide risk reassessment regardless of the total. Document the response, bedside follow-up question, patient's thoughts, plan, intent, means, and actions taken (safety plan, sitter, environmental precautions, provider notification, behavioral health consult, 988 referral if outpatient). 988lifeline.org
5. Document the functional impairment response: Ask the functional impairment question (sometimes called item 10) and document the response: not difficult at all, somewhat difficult, very difficult, or extremely difficult. Although this response does not contribute to the total, it is necessary for complete documentation.
6. Notify the provider when the score is 10 or higher or item 9 is positive: A total at or above 10 or any positive item 9 should prompt provider notification with the score, severity band, item 9 status, functional impairment, and the action taken so far. Include the score in your next SBAR (Situation, Background, Assessment, Recommendation) handoff, and reassess as often as the patient's clinical trajectory requires.

Frequently Asked Questions

Is the PHQ-9 a diagnostic tool?

No, the PHQ-9 serves as a screening tool, not a diagnostic one. A score of 10 or higher suggests possible major depressive disorder but does not confirm the diagnosis. The subsequent clinical interview (performed by a provider or clinician, not the nurse) establishes the diagnosis. Document the score and severity band, not the diagnosis.

What does a positive item 9 trigger?

Any item 9 score above 0 ("several days," "more than half the days," or "nearly every day" of thoughts of self-harm) triggers a documented suicide risk reassessment, regardless of the total score. The chart entry must include the patient's response, the bedside follow-up question, their thoughts, plan, intent, means, and the resulting safety plan or escalation. National Patient Safety Goal 15.01.01 (the Joint Commission's standard for suicide risk reduction) requires this documentation in Joint Commission accredited behavioral health care settings.

How does PHQ-9 differ from PHQ-2?

PHQ-2 includes the first two items of the PHQ-9 (anhedonia and depressed mood) and serves as an ultra-brief entry screen. A PHQ-2 score of 3 or higher prompts escalation to the full PHQ-9 in primary care. Both tools have comparable sensitivity, but PHQ-9 offers substantially higher specificity. This difference is why a positive PHQ-2 leads to the full PHQ-9 instead of being treated as the final answer.

Can a nurse administer PHQ-9 independently?

Yes, a nurse can administer the PHQ-9 independently. It is a self-report instrument and is routinely administered by nursing staff in admission, primary-care, and emergency department settings. The score and the documentation belong to the nurse who administered it; the diagnostic interpretation belongs to a clinician licensed to make a depression diagnosis. Administering and scoring PHQ-9 is within nursing scope; diagnosing major depression from the score is not.

Is PHQ-9 validated for adolescents?

No, the adult PHQ-9 is validated for individuals aged 18 and older. For pediatric populations, use the PHQ-A, which adapts the language for adolescents and includes two additional items: irritability and a different phrasing for suicidality. Administering the adult PHQ-9 to a minor may yield a score that does not align with the validated thresholds for that age group.

How often should PHQ-9 be repeated?

In primary care, clinicians typically repeat the PHQ-9 every 4 to 6 weeks to monitor treatment response. In inpatient settings, the timing depends on clinical changes; readminister the assessment when symptoms shift or when item 9 is positive, indicating the need to reassess the safety plan. Document the rationale for readministration in the chart to ensure the next reader understands why the score was repeated.

Related Guides

• mental and emotional status chartingMental and Emotional Status category. PHQ-9 is in NCP once the structured field ships. Read this guide for the framework that holds depression, anxiety, and mood observations together.
• safety assessment chartingThe bridge guide for item 9 positive responses. The safety follow-up entry that any positive item 9 produces is documented in the safety assessment category.
• GAD-7 documentationThe paired anxiety screen. PHQ-9 and GAD-7 ride together in primary care because depression and anxiety are highly comorbid. Read the GAD-7 guide if the patient endorses worry, restlessness, or irritability.
• SBAR for psychiatric nursingPHQ-9 should appear in the Background section of any psych SBAR. Score, severity band, item 9 status, and the response action are the four elements that transfer during the handoff.
• psychiatric nursing charting overviewPsychiatric charting overview. PHQ-9 is one of several validated instruments the psych framework uses.