When interviewing the resident using the questions in the PHQ-9, what do you do when they answer them all as “no”, but in the charting and documentation, you see they had episodes of crying or tearfulness, pain, insomnia, etc.? Is this information to be incorporated into the PHQ-9 or must we code using only the resident’s actual responses?



Per the RAI, “Obtaining information about mood directly from the resident, sometimes called “hearing the resident’s voice,” is more reliable and accurate than observation alone for identifying a mood disorder.”

While the interview questions must be coded with the resident’s direct answers, the RAI also states:

“Assessors do not make or assign a diagnosis in Section D; they simply record the presence or absence of specific clinical mood indicators. Facility staff should recognize these indicators and consider them when developing the resident’s individualized care plan.”

Keep in mind, the resident may be embarrassed or unable to answer the questions truthfully. I encourage you to consider the following to ensure an effective interview is conducted:

  • Conduct the interview in a private setting.
  • Sit so that the resident can see your face.
  • Be sure the resident can hear you.
  • If you are administering the PHQ-9© in paper form, be sure that the resident can see the print.
  • Explain the reason for the interview before beginning.
    • Suggested language: “I am going to ask you some questions about your mood and feelings over the past 2 weeks. I will also ask about some common problems that are known to go along with feeling down. Some of the questions might seem personal, but everyone is asked to answer them. This will help us provide you with better care.”
  • Try having a different caregiver conduct the interview if there is someone the resident may feel more comfortable with.

The Steps for Assessment can be found in the RAI, Chapter 3, page D-4 and there are additional interview tips located in Appendix D.


Blog by Eleisha Wilkes, RN, RAC-CTA, Clinical Consultant

To learn more about Eleisha and the rest of the Proactive team.