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; in general medical settings, the institution's local protocol governs the same workflow.

How does PHQ-9 differ from PHQ-2?

PHQ-2 includes the first two items of the PHQ-9 - anhedonia and depressed mood - serving 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 clinicians escalate care after a positive PHQ-2 instead of treating it as the final answer.

Can a nurse administer PHQ-9 independently?

Yes. PHQ-9 is a self-report instrument and is routinely administered by nursing staff in admission, primary-care, and ED 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.

By Miranda Niemas, Nursing Student (BSN candidate)

Clinically reviewed by Amy Niemas, RN-BC, BSN, MSW

Last updated: May 26, 2026

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

Quick Reference

The PHQ-9 is a 9-item depression screening tool scored from 0 to 3 for each item over the past 2 weeks. Total scores range from 0 to 27 and correspond to five severity bands. Item 9 addresses thoughts of self-harm and stands alone; any positive response requires a documented suicide risk reassessment, regardless of the total score. The screen is paired with a functional impairment question (how much these symptoms get in the way of work, home, and relationships), which is required for documentation but does not count toward the total.

0-4 minimal; 5-9 mild; 10-14 moderate; 15-19 moderately severe; 20-27 severe
Each item scores 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day), with a recall window of 2 weeks.
A score above 0 on Item 9 (thoughts of self-harm) triggers a documented suicide risk reassessment, regardless of the total score.
The functional impairment question (how much these symptoms get in the way of work, home, and relationships) is required for documentation but does not contribute to the total score.
PHQ-9 is a screen, not a diagnosis; a positive score prompts a clinical interview (performed by a provider or clinician, not the nurse), not a chart label
The PHQ-2 (items 1 and 2) is the standard primary-care entry screen; a PHQ-2 score of 3 or higher escalates to the full PHQ-9.
Validated for adults; pediatric populations should use the PHQ-A instead of the adult PHQ-9.
A complete chart entry includes the total score, the 9 component scores, Item 9 with the response action, the functional impairment response, and the plan.

Your med-surg admission involves a 38 year old woman recovering from a hysterectomy. The intake form is half-finished when the unit clerk hands you the PHQ-9 to complete. She scores a 14, with item 9 marked "several days." You stare at the screen, wondering whether to flag the total, the item 9 response, or both. I faced this exact scenario during my last clinical rotation. The framework that finally made it clear is to address item 9 first, then the total, while always considering functional impairment.

Video coming soon — subscribe to be notified when new episodes drop.

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)

Kroenke, Spitzer, and Williams developed the Patient Health Questionnaire-9 in 2001 as a brief measure of depression severity based on DSM criteria for major depressive disorder. The validation cohort included 6,000 patients from primary-care and obstetrics-gynecology clinics. At a score of 10 or higher (the threshold most programs use to trigger further evaluation), the instrument detected major depression in 88% of patients who actually had it (sensitivity) and correctly screened out 88% of patients who did not (specificity), compared to structured psychiatric interviews. The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for major depressive disorder with a Grade B (high or moderate certainty of moderate net benefit) in its 2023 final statement, naming the PHQ-9 as one of the validated tools that meet this standard. American Academy of Family Physicians (AAFP) guidance for primary-care implementation suggests starting with the PHQ-2 and escalating to the full PHQ-9 only when the brief screen is positive, which aligns with the workflow most med-surg admissions and primary-care visits follow. The American Psychiatric Association's 2010 Practice Guideline for the Treatment of Patients with Major Depressive Disorder recommends integrating clinician- or patient-administered rating-scale measurements into initial and ongoing psychiatric evaluation, and PHQ-9 is the most widely used patient-administered depression rating scale that fits that recommendation. From a documentation standpoint, the score is not the only signal that matters. Item 9 (thoughts of self-harm) carries clinical weight independent of the total score. The Joint Commission's National Patient Safety Goal 15.01.01 (NPSG 15.01.01, effective July 1, 2019), which is the standard for suicide risk reduction, applies to Joint Commission accredited behavioral health care organizations and lists the PHQ-9 as one example of a validated screening tool in the Joint Commission's R3 Report Issue 18 (R3 stands for Requirement, Rationale, Reference, the format the Joint Commission uses to publish standard updates); the NPSG requires that any positive screen produce a documented evidence-based risk assessment, an overall risk-level entry, and a mitigation plan. The goal does not mandate universal screening on general medical units, but its Element of Performance 2 (the patient-population trigger) instructs clinicians to assess medical inpatients with co-occurring behavioral health conditions or recent high-impact diagnoses for suicidal ideation as part of routine clinical evaluation. Charting only the total without breaking out item 9 leaves the next reader without essential safety information. Documenting a positive item 9 without recording a response action leaves a flagged suicidal ideation finding with no follow-up, which is the single worst pattern an audit can find in inpatient psych nursing. The 988 Suicide and Crisis Lifeline (call or text 988) serves as the federally designated default for outpatient and community handoff when a positive screen does not require inpatient escalation.

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)
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)
Depression Screening: A Practical Strategy — Maurer DM, Raymond TJ, Davis BN. Am Fam Physician. 2018;98(8):508-515 (2018)
988 Suicide and Crisis Lifeline (federally designated) — SAMHSA / Vibrant Emotional Health, 988 Suicide and Crisis Lifeline (2024)
Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition — American Psychiatric Association, October 2010 (2010)
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 PHQ-9 is a 9-item self-report depression screen aligned with the DSM criteria for major depressive disorder. Patients rate how often each of the nine listed problems has bothered them over the past 2 weeks on a 0-to-3 scale: 0 means not at all, 1 means several days, 2 means more than half the days, and 3 means nearly every day. Total scores range from 0 to 27 and correspond to five severity bands. Kroenke and colleagues validated the instrument in 2001 in primary care and obstetrics-gynecology clinics; at a score of 10 or higher (the threshold most programs use to trigger further evaluation), the screen detected major depression in 88% of patients who actually had it and correctly screened out 88% of patients who did not, compared to structured psychiatric interviews. This is why a score of 10 is the most common trigger for further evaluation. The PHQ-9 appears across various settings: med-surg admissions, primary care, ED behavioral health holds, inpatient psych admissions, perinatal screening, oncology and chronic-illness clinics, and ICU step-down units where pre-admission psychiatric history is relevant. It is validated for adults. Pediatric populations use the PHQ-A, which adapts the language for adolescents and adds two items. Remember, the PHQ-9 is a screening tool, not a diagnostic instrument. A positive score prompts a clinical interview (performed by a provider or clinician, not the nurse) and, in inpatient settings, a documented plan, rather than a labeled diagnosis on the chart. Charting "PHQ-9 score 18, severity moderately severe" is correct. However, charting "patient has major depression, PHQ-9 18" is incorrect, as the score alone does not establish a clinical diagnosis.

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).

Item 1 - Anhedonia

Little interest or pleasure in doing things. Patients often report a flat or absent response to activities they previously enjoyed. This symptom is one of the two cardinal DSM indicators of major depression and forms the first half of the PHQ-2 entry screen.

Item 2 - Depressed Mood

Feeling down, depressed, or hopeless. This is the other cardinal DSM symptom and the second item of the PHQ-2. Items 1 and 2 together drive the PHQ-2 escalation rule; a PHQ-2 score of 3 or higher escalates to the full PHQ-9.

Item 3 - Sleep Disturbance

Trouble falling or staying asleep, or sleeping too much. This item is intentionally bidirectional because depression can present as insomnia in some patients and hypersomnia in others. Document which direction the patient endorsed if available; the structured field captures only the score.

Item 4 - Fatigue

Feeling tired or having little energy. It's easy to over-attribute this to medical illness, postoperative recovery, or chemotherapy in inpatient populations. The score reflects the patient's experience; the differential diagnosis emerges during the clinical interview that follows.

Item 5 - Appetite Disturbance

Poor appetite or overeating. This item is also bidirectional. Watch for confounding factors such as NPO status, post-op nausea, or active GI disease in med-surg patients; do not zero out the item just because the patient is NPO.

Item 6 - Worthlessness or Guilt

Feeling bad about yourself or believing you are a failure or have let yourself or your family down. This item captures the cognitive distortion aspect of depression and frequently scores high in patients with high item 9 risk; these two items often correlate more than the others.

Item 7 - Concentration

Trouble concentrating on tasks, such as reading the newspaper or watching television. This is a pure attention symptom. In hospitalized patients, screen for delirium and medication-related cognitive changes before attributing item 7 to depression alone.

Item 8 - Psychomotor Changes

Moving or speaking so slowly that others have noticed, or being so fidgety or restless that you have been moving around a lot more than usual. This item is bidirectional. Staff and family can observe it, making it a useful collateral check; if the score does not match what the unit team has observed, consider a follow-up question.

Item 9 - Thoughts of Self-Harm

Thoughts that you would be better off dead or of hurting yourself in some way. This is the single most important PHQ-9 item to document separately. A score above 0 triggers a documented suicide risk reassessment, regardless of the total score. The "Item 9: The Suicidality Flag and What It Triggers" section below walks through the chart entry that a positive item 9 requires.

Functional Impairment Item (Sometimes Called Item 10)

How difficult have these problems made it for you to work, take care of things at home, or get along with other people? This question is asked alongside the score but does not contribute to the total. It is a separate field with four response options (not difficult at all, somewhat difficult, very difficult, extremely difficult) and is required for documentation completeness. A total score of 18 with "extremely difficult" impairment indicates a different patient than a total of 18 with "not difficult at all," and the impairment response carries that distinction into the chart.

Scoring, Severity Bands, and the Functional Impairment Item

Scoring involves straightforward arithmetic: sum the 0-to-3 scores across all 9 items to obtain a total ranging from 0 to 27. The severity bands are as follows: 0 to 4 indicates minimal, 5 to 9 indicates mild, 10 to 14 indicates moderate, 15 to 19 indicates moderately severe, and 20 to 27 indicates severe. A score of 10 or higher is the most clinically meaningful threshold and is the trigger for further evaluation in most depression-screening programs. The functional impairment question (how much these symptoms get in the way of work, home, and relationships) accompanies the score but does not contribute to the total; document the response in a separate field. If any of the 9 items are skipped, the instrument cannot be scored. Partial completion is invalid and should be documented as follows: "PHQ-9 partial: 7 of 9 items completed, items 6 and 9 declined, total not calculable, declined items documented separately." A patient who declines item 9 signals a significant clinical concern. While this decline does not contribute to the score, it warrants a follow-up question and a chart entry. Many institutions treat a declined item 9 similarly to a positive item 9 for safety-reassessment purposes.

Item 9: The Suicidality Flag and What It Triggers

Item 9 is the suicide risk center of every PHQ-9 chart entry. Any score above 0 ("several days," "more than half the days," or "nearly every day" of thoughts that you would be better off dead or of hurting yourself in some way) triggers a documented suicide risk reassessment, regardless of the total PHQ-9 score. A total score of 8 (mild) with item 9 marked 1 may look like a low-risk patient at the total-score level, and that is exactly the situation a fast scan of the chart can miss. However, the standalone item 9 response requires the same suicide risk follow-up as a higher-scoring positive screen. In Joint Commission accredited behavioral health care settings, NPSG 15.01.01 requires a documented evidence-based risk assessment of every positive screen (Element of Performance 2, the patient-population trigger; and Element of Performance 3, the timing of the assessment), an overall risk-level entry plus mitigation plan in the chart (Element of Performance 4), and follow-up policies at discharge (Element of Performance 6); the Joint Commission's R3 Report Issue 18 (Requirement, Rationale, Reference) lists the PHQ-9 as one example of a validated screening tool that meets this standard. In general medical settings, the goal does not mandate the same workflow, but the chart-entry expectation is the same when item 9 is positive. The chart entry must capture the item 9 response, the bedside follow-up question (open-ended, ideally "tell me more about that"), the patient's stated thoughts, plan, intent, access to means, and the resulting safety plan, sitter order, environmental precautions, or escalation to a provider or behavioral health consult. Documenting a positive item 9 without a corresponding response action is the worst pattern an audit can find in inpatient psych nursing, both clinically and medico-legally. For outpatient settings or discharge handoff where inpatient escalation is not indicated, the federally designated 988 Suicide and Crisis Lifeline (call or text 988, chat at 988lifeline.org) serves as the default community resource and should appear in the documented plan.

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

In primary care workflows, providers rarely administer the PHQ-9 first. Most outpatient practices and many inpatient admission processes use the PHQ-2, which includes the first two items of the PHQ-9 (anhedonia and depressed mood), as the entry-level screen. The AAFP recommends starting with the PHQ-2; a score of 3 or higher escalates to the full PHQ-9. Sensitivity for major depression is comparable between the PHQ-2 and PHQ-9 in most populations, but the PHQ-9 has substantially higher specificity (it correctly screens out more patients who do not have major depression). This difference explains why a positive PHQ-2 escalates to the full assessment, while a negative PHQ-2 concludes at the brief screen. When a unit administers the full PHQ-9 on every admission, this reflects a deliberate institutional choice, often due to high baseline depression prevalence in admission populations, and should be documented in the local screening protocol. The GAD-7 frequently accompanies the PHQ-9 because depression and anxiety often coexist. The PHQ-4, an ultra-brief 4-item screen developed by Kroenke and colleagues in 2009, combines the PHQ-2 and GAD-2 into a single instrument, detecting either condition through two screening dimensions. If you see the PHQ-9 administered without the GAD-7 in a patient with anxiety symptoms, the comorbid anxiety is at high risk of being overlooked; adding a paired GAD-7 is the next step.

PHQ-9 Documentation in NurseChartingPro

NurseChartingPro captures depression-related observations in the Mental and Emotional Status category of psychiatric charting. A future update will add a structured PHQ-9 field to the Mental and Emotional Status category, with the nine component scores, total, severity band, item 9 standalone documentation, and functional impairment response. Until the structured field is available, document the score in the Notes field using the chart entry pattern outlined later in this guide: total, nine component scores, item 9 with response action, functional impairment response, severity band, and plan. When item 9 is positive, document the safety follow-up as a separate Safety Assessment entry. The Notes pattern transfers smoothly to the structured field when it arrives.

Common Mistakes

Charting Only the Total Without Breaking Out Item 9

Weak: PHQ-9 total 14 (moderate).

Strong: PHQ-9 total 14 (moderate). Component scores 1: 2, 2: 2, 3: 2, 4: 2, 5: 1, 6: 2, 7: 1, 8: 1, 9: 1 (several days). Item 9 positive at "several days." Bedside follow-up: patient denies plan, denies access to means, no recent self-harm, agreed to safety plan with husband as designated support. Functional impairment "very difficult." Notified provider at 1015, behavioral health consult ordered, sitter not indicated at this time. Patient education at the bedside: coping skills and stress-relief techniques (paced breathing, grounding) reviewed with patient. 988 Lifeline provided in writing for discharge. Reassess at 1400.

PHQ-9 without the 9 component scores hides the most clinically important data point: item 9. The next reader of the chart cannot tell whether the moderate-range total includes a positive suicidality response without the component breakdown. Always chart the components and call out item 9 separately.

Treating PHQ-9 as a Diagnosis

Weak: Patient has major depression. PHQ-9 score of 18.

Strong: PHQ-9 score 18, moderately severe range. Score consistent with possible major depression; clinical interview pending. Provider notified for diagnostic evaluation.

The PHQ-9 serves as a screening tool, not a diagnostic measure. A score in the moderately severe range suggests major depression but does not confirm the diagnosis without a clinical interview. Documenting "patient has major depression" based solely on a PHQ-9 score overreaches and may require the next provider to correct.

Missing the Functional Impairment Item

Weak: PHQ-9 total 12, item 9 negative.

Strong: PHQ-9 total 12 (moderate), item 9 negative, functional impairment "very difficult." Patient reports inability to complete work tasks for the past 2 weeks.

The functional impairment question is essential for documentation completeness, even though it does not contribute to the score. Two patients with the same total can experience very different functional impacts. The impairment response distinguishes these differences in the chart and informs the clinical interview.

Scoring a Partial PHQ-9

Weak: PHQ-9 total 9 (mild); patient declined item 9.

Strong: PHQ-9 partial: 8 of 9 items completed, item 9 declined, total not calculable. Items 1-8 sum to 9 (sub-threshold range, but item 9 is missing). Patient declined item 9, treated as a suicide risk indicator per unit policy. Completed bedside follow-up; patient denied current ideation, agreed to safety plan, and provider notified at 1230.

You cannot score the PHQ-9 if any item is skipped. Document a partial PHQ-9 as such, without summing and labeling it with a severity band. A declined item 9 is a significant safety signal and should be documented and followed up like a positive response according to most institutional policies.

Using the Adult PHQ-9 on an Adolescent

Weak: Patient is 15. PHQ-9 administered, score 11, moderate.

Strong: Patient is 15. Adolescent depression screen completed using PHQ-A (PHQ-9 modified for adolescents); score 11. Adult PHQ-9 not used because patient is under 18.

The PHQ-9 is validated for adults. For pediatric populations, use the PHQ-A, which adapts the language for adolescents and includes two additional items: irritability and suicidality phrasing. Administering the adult PHQ-9 to a minor may yield a score that does not align with the validated thresholds for that age group.

Mrs. ChenAge 38 — Postoperative day 1 after laparoscopic hysterectomy, med-surg admission, no prior psychiatric history documented

fictional patient

Scenario

As the day shift med-surg nurse caring for Mrs. Chen, a fictional 38 year old admitted overnight after a laparoscopic hysterectomy, I follow the unit's admission protocol, which includes a PHQ-9 for every patient. The night shift started the intake form, but they left the PHQ-9 section blank. I complete it with the patient at 1000, and the score returns 14, with item 9 marked "several days." The patient is alert, oriented, hemodynamically stable, and denies pain above 3 out of 10. She has no documented psychiatric history. The on-call provider is in a procedure for the next hour.

Chart Entry

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.

Annotations

Total + 9 component scores broken out:: The total alone hides which specific items are positive. Listing all 9 components makes item 9 immediately visible to the next reader and supports the audit trail.
Item 9 flagged separately and followed up:: The standalone item 9 entry, the bedside follow-up question, and the safety plan together satisfy National Patient Safety Goal 15.01.01 documentation expectations. A positive item 9 without a documented follow-up is the worst pattern an audit can find.
Functional impairment captured:: The functional impairment field is required even though it does not score. "Very difficult" alongside a total of 14 communicates more clinical impact than the total alone.
988 Lifeline included in plan:: The federally designated crisis line appears in the documented plan because the patient will eventually be discharged. The 988 reference is not a substitute for the inpatient response (consult, sitter, environmental precautions) but it is a required handoff resource.
Reassessment frequency specified:: Reassessing item 9 every shift until the behavioral health consult is complete is what closes the documentation loop. Charting a positive item 9 once and then never reassessing is a common gap an audit will catch.

Pro Tips

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.
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.
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.
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).
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.
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.

Chart smarter with Nurse Charting Pro

Structured assessments, AI-generated narratives, and end-of-shift crypto-shredding — built for nurses who care about documentation quality.

App Store Google Play