Screening Tools: How to Score Them and Document the Result
Facts checked against the primary sources listed below. Last reviewed . Last updated: . See sources.
How do you document a screening tool score in a progress note?
Name the tool and version, record the total score and the band or cutoff, compare it with the last score, and put your interpretation in the Assessment. In a SOAP note the score belongs in Objective, and in a DAP note it belongs in Data. These guides cover the common mental health and substance use screens.
Each guide below explains what one screening tool is, who developed it, how it is scored, and where its result belongs in a progress note. They link to the official forms instead of reproducing the questions, and they name the usage terms the owners publish.
WellNotes does not administer or score screening tools. You give the tool and score it. WellNotes drafts your session note from what you type or dictate, so the score and your interpretation end up in a note you review and edit.
Screening tool guides
| Tool | Screens for | Score range or length | Guide |
|---|---|---|---|
| PHQ-9 | Depression symptom severity | 9 items, total 0 to 27 | PHQ-9 scorer, scoring and documentation |
| GAD-7 | Anxiety, probable generalized anxiety disorder | 7 items, total 0 to 21 | GAD-7 scoring and documentation |
| PCL-5 | PTSD symptoms (20 DSM-5 symptoms) | 20 items, total 0 to 80 | PCL-5 scoring and documentation |
| C-SSRS | Suicidal ideation and behavior | Screeners of 2 to 6 questions, plus full scale | C-SSRS documentation |
| CAGE, AUDIT-C, DAST | Alcohol and drug use | 4 questions, 3 questions, 20 or 10 items | Substance use screening tools |
What does a screening tool score add to a progress note?
A score gives a reviewer a fixed, comparable measure next to your narrative. It supports medical necessity and shows change over time without long prose. It does not replace clinical judgment: a screening result is one finding, and the note should show how you interpreted it.
Where does the score go in a SOAP or DAP note?
In a SOAP note the tool, version, date, total score and band or cutoff go in Objective, and your interpretation goes in Assessment. In a DAP note the same facts go in Data and the interpretation in Assessment. See the SOAP note template and the DAP note template for the full structure, and the progress notes cheat sheet for a one-page reminder.
What should every documented screen include?
- The full name of the tool and the version or time frame used.
- The date, and whether the client self-completed it or you asked the questions.
- The total score and the band, cutoff or risk level the form reports.
- The prior score and the trend.
- Your interpretation and any action taken, in the Assessment and Plan.
Are screening tools free to use?
It depends on the tool. The official PHQ-9 and GAD-7 forms say no permission is required to reproduce, translate, display or distribute them. The VA says the PCL-5 is in the public domain. Columbia says the C-SSRS and its training are free for community and healthcare settings. For the CAGE, AUDIT-C and DAST the licensing terms were not confirmed, so check the owner. Each guide gives the exact wording and source.
Frequently Asked Questions
Should I write the screening tool questions in the note?
No. Record the tool, version, date, score and result. The questions are on the form, and some owners restrict copying, so keep the note to the result and your interpretation.
How often should I repeat a screening tool?
Set the interval in your treatment plan or follow your agency or payer requirement. These guides do not set a repeat schedule.
Does a high score mean the client has the condition?
No. These tools screen for and quantify symptoms. A diagnosis requires a clinical evaluation by the treating clinician, and your note should say so in your own words.
Does WellNotes administer or score these tools?
No. The WellNotes note app does not administer or score screening tools: you give and score the tool. The free scorer on the PHQ-9 guide only adds up the item scores you enter, in your browser, and nothing is saved. WellNotes drafts your session note from what you type, and you review the result you entered.
Which note format is best for recording scores?
Any format with a place for measured data works. SOAP uses Objective, DAP uses Data. Use the format your agency or payer requires.
Related references
Sources
- PHQ Screeners (Pfizer): download the PHQ-9 and GAD-7 forms
- VA National Center for PTSD: PTSD Checklist for DSM-5 (PCL-5)
- Columbia Lighthouse Project: about the C-SSRS
- Ewing. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252(14):1905-1907
- Bush et al. The AUDIT alcohol consumption questions (AUDIT-C). Arch Intern Med 1998;158(16):1789-1795
- NIDA Data Share: Drug Abuse Screening Test
This page is general reference information, not clinical, coding, or legal advice. Scoring rules and usage terms can change, so confirm them on the instrument owner's current materials and with your payer or supervisor before relying on them. WellNotes does not administer or score screening tools. The treating clinician interprets every result.
Draft the session note with the score in it
Type or dictate the session, include the score and your interpretation, and WellNotes drafts the note in SOAP, DAP, or BIRP. You review and edit every note.