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How-toPatient Health Questionnaire Scoring
By bmfrank
Category: How-to. Viewed 373 times. Created June 2014.     Disclaimer.   
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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.

                 
Begin with the Patient Health Questionnaire-2. Is the patient's total score 3 or higher?
 
 
 
 

NO

YES







Nothing further is needed.
Have patient fill out the out the Patient Health Questionnaire-9 (PHQ-9).
Is the individual's score between 5-9?
YES
Individual can be counseled by nurse in office or fax callback form and individual will be contacted within 72 hours. Fax# 701-235-2476
If patient refuses fill out refusal for referral form.





NO




 
Is the patient's total score lower than 5?
Is the individual's score between 10-14?
YES
Fax callback form, refer for private counselor, provide Suicide Prevention Hotline # 1-800-273-8255.
If patient refuses fill out refusal for referral form.



YES


NO




 
Nothing further is needed.
Is the individual's score between 15-19?
YES
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.
If patient refuses fill out refusal for referral form.





NO




 
 
Is the individual's score >20?
YES
Is this person actively suicidal? Do they have a plan? Individual should be taken to the hospital for further evaluation.