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Appendix H: PHQ-9-OV
Staff Assessment of Resident Mood (PHQ-9-OV)
Resident: Identifier: Date:
Section D
D0500. Staff Assessment of Resident Mood (PHQ-9-OV)
Do not conduct if Resident Mood Interview (D0200—D0300) was completed
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
en move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes
(enter 0–3 in column 2)
2. Symptom Frequency
0. Never or 1 day
1. 2–6 days (several days)
2. 7–11 days
(half or more of the days)
3. 12–14 days
(nearly every day)
1.
Symptom
Presence
2.
Symptom
Frequency
⬇ Enter Scores ⬇
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energ y
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or
have let yourself or your family down
G. Trouble concentrating on things, such as reading the
newspaper or watching television
H. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless that
you have been moving around a lot more than usual
I. States that life isn't worth living, wishes for death, or
attempts to harm self
J. Being short-tempered, easily annoyed
D0600. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom
Frequency. Total score must be between 00 and 30.
D0650. Safety Notification – Complete only if D0200|1 = 1 indicating possibility of
resident self harm
Enter Score Add scores for all frequency responses in Column 2, Symptom
Frequency. Total score must be between 00 and 30.
Enter Code Was responsible staff or provider informed that there is a potential for
resident self harm?
0. No
1. Yes
