By Miranda, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed clinical nurse.

Last updated: April 26, 2026

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

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.

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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 cutoff of 10, the instrument achieved 88% sensitivity and 88% specificity for major depression compared to structured psychiatric interviews. The U.S. Preventive Services Task Force recommends screening adults for major depressive disorder with a Grade B in its 2023 final statement, naming the PHQ-9 as one of the validated tools that meet this standard. 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. Joint Commission NPSG 15.01.01 (effective July 1, 2019) applies to Joint-Commission-accredited behavioral health care organizations and explicitly names the PHQ-9 in the R3 Report Issue 18 examples list of validated screening tools; it 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 EP 2 note instructs clinicians to assess medical inpatients with comorbid 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 clinician without essential safety information. Documenting an item-9 positive finding without a recorded response action results in a flagged suicidal-ideation finding with no follow-up, which represents the single worst chart-audit pattern 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.
  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 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 cutoff of 10, it achieved 88% sensitivity and 88% specificity for major depression against structured psychiatric interviews. This validation supports using 10 as the most common screening trigger. 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 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.

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 item is the single most important to document separately. A score above 0 triggers a documented suicide-risk reassessment, regardless of the total score. The next section outlines the chart-entry pattern.

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. The cutoff of 10 serves as the most clinically meaningful threshold and is the trigger for further evaluation in most depression-screening programs. The functional impairment question 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 defensible 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 serves as the YMYL 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. Chart audits frequently miss this pattern: a total score of 8 (mild) with item 9 marked 1 may appear as a low-risk patient at the total-score level. 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 (EPs 2 and 3), an overall risk-level entry plus mitigation plan in the chart (EP 4), and follow-up policies at discharge (EP 6); the R3 Report Issue 18 names PHQ-9 in its examples list of validated screening tools. 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 an item-9 positive without a corresponding response action represents the worst chart-audit pattern 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. 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 ([see the GAD-7 documentation guide](/guides/gad-7-documentation)) is the next step.

PHQ-9 Documentation in NurseChartingPro

NurseChartingPro captures depression-related observations in the Mental and Emotional Status category of psychiatric charting. The structured PHQ-9 field, which includes the nine component scores, total, severity band, item-9 standalone documentation, and functional-impairment response, is on the Phase 5 roadmap. It will join the Mental and Emotional Status category once implemented. 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. This handoff will integrate PHQ-9 once the structured field arrives, allowing the documentation habit to transfer smoothly when the feature is implemented.

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, reassess at 1400.

PHQ-9 without the 9 component scores hides the most clinically important data point: item 9. The next clinician reading 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 serves as a defensible 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 cutoffs 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 intensivist is not on the case, and 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: 988 Suicide and Crisis Lifeline (call or text 988, chat at 988lifeline.org) provided in writing with discharge packet.
- Reassess PHQ-9 component item 9 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 Joint Commission NPSG 15.01.01 documentation expectations. A positive item 9 without a documented follow-up would be the worst chart-audit pattern.
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 cadence specified:
Q-shift item-9 reassessment 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 in the chart-audit pattern.

Pro Tips

  • 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.
  • The 2-Week Recall Phrase Is Load-Bearing: 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 cutoffs, and the score has to be readministered with the correct framing.
  • 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 serves as a defensible 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 does. Keeping that distinction in your chart entry protects the next provider from having to walk back an overreach.

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