Screening Tools
What screening tools are in mental health care, common examples with their score ranges, how screening differs from diagnosis, and how to document results in a progress note.
Quick Answer
Screening tools are brief, standardized questionnaires or structured questions that flag people who may have a condition or a safety risk and need a fuller assessment. Common examples are the PHQ-9 (depression), GAD-7 (anxiety), PCL-5 (PTSD), AUDIT (alcohol use), the C-SSRS screener and ASQ (suicide risk) and the MDQ (bipolar spectrum). A positive screen is not a diagnosis: it tells you what to assess next. In a note, record the tool, date, total score, what the score band means, any risk item answered positively, and what you did about it.
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Definition
A screening tool is a short, standardized measure used to identify people who may have a condition, symptom pattern or risk that needs further assessment. Most are self-report questionnaires that take a few minutes; some, such as suicide risk screens, are short sets of questions the clinician asks.
Screening is not diagnosis. A screen is designed to catch most people who might have a problem, so it also flags some who do not. A positive result tells you what to assess next; the diagnosis comes from a clinical interview against diagnostic criteria. A negative result does not rule a problem out if your own observations suggest otherwise.
Many of the same tools are repeated over time as outcome measures to track change. When you use a tool that way, chart it as a measure of severity and change, not as a new screen.
Common mental health screening tools
Use the current published version of each tool and its own scoring rules. Score bands below are the commonly published ones; they are guides, not diagnoses.
| Tool | Screens for | Format and scoring |
|---|---|---|
| PHQ-9 | Depression symptoms over the past 2 weeks | 9 items, 0–27. Bands: 5 mild, 10 moderate, 15 moderately severe, 20 severe. Item 9 asks about thoughts of death or self-harm and needs same-day follow-up if positive. |
| PHQ-2 | Depression (first step) | First 2 items of the PHQ-9; a score of 3 or more is usually followed by the full PHQ-9. |
| GAD-7 | Anxiety symptoms over the past 2 weeks | 7 items, 0–21. Bands: 5 mild, 10 moderate, 15 severe. |
| PCL-5 | PTSD symptoms over the past month | 20 items, 0–80. The National Center for PTSD suggests a provisional cut-point of 31–33. |
| AUDIT / AUDIT-C | Hazardous or harmful alcohol use | AUDIT: 10 items, 0–40; 8 or more suggests hazardous or harmful drinking. AUDIT-C uses the first 3 items. |
| C-SSRS screener | Suicide risk | Short set of yes/no questions about wishes to be dead, suicidal thoughts, method, intent, plan and recent behavior; answers set the follow-up level. |
| ASQ | Suicide risk in youth and in medical settings | 4 questions (plus a fifth on current thoughts if any are positive), from NIMH; any yes is a positive screen that needs further assessment. |
| MDQ | Bipolar spectrum symptoms | Self-report questionnaire about past periods of elevated mood; a positive result needs a full assessment for bipolar disorder. |
| EPDS | Perinatal depression | 10 items; item 10 asks about thoughts of self-harm and needs follow-up if positive. |
| CRAFFT | Substance use in adolescents | Short interview or self-report for ages 12–21; 2 or more yes answers on part B suggests higher risk. |
Screening vs assessment. Screening is brief and given to many people to find who needs a closer look. Assessment is the full clinical evaluation, such as an intake interview, a risk assessment or a diagnostic interview, that decides what is going on and what to do.
How to document screening results in a progress note
Record the tool name, the date it was completed, the total score and band, any individual item that changes what you do (such as a suicide item), how the score compares with earlier results, and the action you took. If you do not act on a positive screen, say why.
Weak documentation: “PHQ-9 done. Positive.”
Stronger documentation: “PHQ-9 completed in session: 16 (moderately severe), up from 11 four weeks ago. Item 9 scored 1 (several days); followed with a suicide risk assessment today (see below).”
Screening results in a SOAP note
Scores usually go in Objective, with the follow-up in Assessment and Plan. A short fictional example:
Subjective: Fictional adult client, 41, outpatient, session 5 for depression. Reports low mood most days for the past month after losing his job, with poor sleep and less interest in seeing friends.
Objective: PHQ-9: 16 (moderately severe), up from 11 at intake four weeks ago; item 9 scored 1 (several days). GAD-7: 8 (mild), unchanged. AUDIT-C: 2. Followed item 9 with direct questions: reports passing thoughts that “it would be easier not to wake up” on two days this week, most recently yesterday; denies a current wish to die, thoughts of killing himself, intent, plan, preparation or rehearsal; denies past suicide attempts or self-harm. Reports no access to firearms. Medications are present at home; he agrees that his wife will secure them as part of today’s safety plan. Lives with his wife, whom he names as a support, and describes plans to apply for jobs. Alert and oriented; affect restricted and congruent; thought process linear.
Assessment: Worsening depression and recent job loss increase concern despite the absence of current suicidal intent or a plan. Therapist assesses acute suicide risk as low, not absent, based on today’s direct assessment, no attempt history, future-oriented plans, identified family support and willingness to use the safety plan and secure medications. Continued outpatient care with closer follow-up is appropriate today; reassess if thoughts, intent, access to means or ability to stay safe change.
Plan: Increase to weekly sessions; behavioral activation plan for daily activity. With client’s consent, therapist will contact his primary care physician this week about the rise in PHQ-9 and an evaluation for medication. Completed a written safety plan with warning signs, coping steps and contacts; client will call or text 988 if thoughts of suicide increase and call 911 or go to the nearest emergency department if he feels unable to keep himself safe. Repeat PHQ-9 at each session.
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Tips for documenting screening tools
Name the exact tool and date: Write “PHQ-9 completed 25 Oct” rather than “depression screen,” so the next reader knows what the number means.
Give the score and the band: Record the total and what it means on that tool’s published scoring, such as “GAD-7: 12 (moderate).”
Chart risk items separately: Suicide or self-harm items, such as PHQ-9 item 9 or EPDS item 10, need their own line and a same-day follow-up assessment if positive.
Compare with earlier scores: Change over time is often more useful than a single score. Note the previous result and date.
Record what you did: A score with no action looks like an unaddressed finding. Note the follow-up, referral or reason no action was needed.
Keep screens and diagnoses apart: Write “positive screen for PTSD symptoms” until a full assessment supports a diagnosis.
Common mistakes to avoid
- Treating a positive screen as a diagnosis: a screen tells you what to assess next, not what the person has
- Score with no follow-up: a positive suicide item charted without a risk assessment is a serious gap
- Unnamed tools: “anxiety screen positive” does not say which tool, which version or what score
- Ignoring clinical judgment: a low score does not override what you observe in the session
- Copying old scores forward: record the date each score was actually completed
Frequently asked questions
What are screening tools in mental health?
Screening tools are short, standardized questionnaires or structured questions used to find people who may have a condition or safety risk and need a fuller assessment. Examples include the PHQ-9 for depression, GAD-7 for anxiety, PCL-5 for PTSD, AUDIT for alcohol use and the C-SSRS screener or ASQ for suicide risk.
What is the difference between a screening tool and a diagnostic assessment?
A screening tool is brief and flags who might have a problem. A diagnostic assessment is a full clinical evaluation against diagnostic criteria that decides whether a condition is present. A positive screen leads to an assessment; it is not a diagnosis on its own.
What do PHQ-9 scores mean?
The PHQ-9 is scored 0 to 27. The published bands are 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately severe and 20–27 severe depression symptoms. Any positive answer to item 9, about thoughts of death or self-harm, needs a same-day follow-up assessment whatever the total score.
How do you document a screening tool in a progress note?
Record the tool name, date completed, total score and band, any risk item answered positively, the previous score for comparison and what you did about the result. For example: “GAD-7: 12 (moderate), down from 16 on 1 Oct; continue current plan.”
Which screening tools are used for suicide risk?
Common options include the Columbia Suicide Severity Rating Scale (C-SSRS) screener and NIMH’s Ask Suicide-Screening Questions (ASQ). Depression measures such as PHQ-9 item 9 also flag thoughts of death or self-harm. Any positive screen should be followed by a direct risk assessment, documented in the note.
Related guides: screening measures in progress notes · outcome measures · risk assessment · severity rating · phrases for documenting suicidal ideation.
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Further Reading
- National Center for PTSD: PCL-5 — The PCL-5 measure, scoring and its guidance on provisional cut-points.
- NIMH ASQ Suicide Risk Screening Toolkit — The Ask Suicide-Screening Questions and the follow-up pathway after a positive screen.
- Screening measures in progress notes — How to record scores, follow-up and change over time in routine notes.