The purpose of this flowchart is to provide instruction as to when to refer individuals based on their Patient Health Questionnaire (PHQ) score. Please remember that nursing judgement overrides any score so refer patients accordingly.
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Begin with the Patient Health Questionnaire-2.
Is the patient's total score 3 or higher?
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NO
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YES
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Nothing further is needed.
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Have patient fill out the out the Patient Health Questionnaire-9 (PHQ-9).
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Is the individual's score between 5-9?
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Individual can be counseled by nurse in office or fax callback form and individual will be contacted within 72 hours.
Fax# 701-235-2476
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If patient refuses fill out refusal for referral form.
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NO
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Is the patient's total score lower than 5?
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Is the individual's score between 10-14?
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Fax callback form, refer for private counselor, provide Suicide Prevention Hotline # 1-800-273-8255.
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If patient refuses fill out refusal for referral form.
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YES
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NO
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Nothing further is needed.
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Is the individual's score between 15-19?
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Is this person actively suicidal? Do they have a plan? Can family come stay with them? Individual should be taken to the hospital for further evaluation.
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If patient refuses fill out refusal for referral form.
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NO
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Is the individual's score >20?
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Is this person actively suicidal? Do they have a plan? Individual should be taken to the hospital for further evaluation.
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