Choose
Match the measure to the clinical question, patient, setting, age, language, and intended use.
BH
Brooke Harbor Health System
PMHNP Clinical Learning Environment
PMHNP Clinical Toolbox
Clinical Workflow ToolPoint-of-care support for a defined clinical task.
Rating Scales & Screening
Use validated measures to structure inquiry, quantify symptom burden, support clinical reasoning, and follow change over time. Interpret each score as one piece of evidence within the full clinical assessment.
Clinical application
Using this resource
Apply these prompts within the simulated clinical context. They support—but do not replace—clinical judgment, supervision, consultation, current guidance, local policy, law, or emergency procedures.
Use this when
- A validated measure could help answer a defined screening, severity, monitoring, or treatment-response question.
Clarify first
- Verify the tool, version, population, purpose, timeframe, administration method, scoring guidance, permissions, and limits before use.
Act now
- Interpret the result with the interview, function, context, baseline, and other clinical evidence rather than treating the score as a diagnosis.
- Follow up positive, unexpected, or discordant responses and use the same appropriate measure when tracking meaningful change over time.
Document and communicate
- Record the measure and version, date, score, clinical meaning, limitations, relevant follow-up, and how the result informed the next decision.
Escalate or consult when
- A response indicates an immediate safety or medical concern, a major discrepancy requires urgent assessment, or the result cannot be interpreted safely within the current context.
Core workflow
From selection to measurement-based follow-up
Administer
Use the correct version, timeframe, instructions, and administration method. Do not silently alter items.
Interpret
Apply the appropriate scoring guidance while integrating interview findings, context, function, and safety.
Document
Record the measure, version, date, score, interpretation, limitations, and action taken.
Trend
When clinically useful, repeat the same measure and compare scores alongside the patient’s reported experience.
Measure library
Mood & anxiety
Brief patient-reported screeners that support symptom detection, severity assessment, and measurement-based follow-up.
PHQ-9Official screener
Patient Health Questionnaire-9
Depressive symptom severity and monitoring
- Format
- Patient-reported · 9 items
- Source
- PHQ Screeners
GAD-7Official screener
Generalized Anxiety Disorder-7
Anxiety symptom severity and monitoring
- Format
- Patient-reported · 7 items
- Source
- PHQ Screeners
MDQView PDF
Mood Disorder Questionnaire
Screening for possible bipolar-spectrum symptoms
- Format
- Patient-reported · screening only
- Source
- Oregon Health & Science University
Measure library
Safety & trauma
Structured resources that support suicide-risk inquiry and trauma-related symptom screening without replacing a full clinical assessment.
C-SSRSChoose official version
Columbia Suicide Severity Rating Scale
Suicidal ideation and behavior assessment
- Format
- Multiple versions · select for setting and purpose
- Source
- Columbia Lighthouse Project
PC-PTSD-5Official resource
Primary Care PTSD Screen for DSM-5
Brief screen for probable PTSD
- Format
- Patient-reported · 5 scored items
- Source
- VA National Center for PTSD
PCL-5Official resource
PTSD Checklist for DSM-5
PTSD symptom severity and provisional assessment
- Format
- Patient-reported · 20 items
- Source
- VA National Center for PTSD
Measure library
Substance use & withdrawal
Screening and clinician-rated withdrawal tools that must be interpreted in the context of history, examination, vital signs, and level-of-care needs.
AUDIT-COfficial resource
Alcohol Use Disorders Identification Test–Consumption
Brief alcohol-use screening
- Format
- Patient-reported or clinician-administered · 3 items
- Source
- U.S. Department of Veterans Affairs
CIWA-ArNot copyrighted
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised
Alcohol-withdrawal symptom severity
- Format
- Clinician-rated · requires clinical context
- Source
- MDCalc clinical reference
Measure library
Symptom-specific & medication monitoring
Focused tools for obsessive-compulsive symptoms, eating-disorder screening, involuntary movements, insomnia, and psychosis.
Y-BOCSPermission required
Yale-Brown Obsessive Compulsive Scale
Clinician-rated OCD symptom severity; copyrighted and requires permission from the developers before use
- Format
- Semistructured interview · training and correct administration matter
- Source
- OCD Scales, LLC (Goodman and colleagues)
AIMSPublic-domain PDF
Abnormal Involuntary Movement Scale
Detection and monitoring of abnormal involuntary movements
- Format
- Clinician-rated · examination procedure required
- Source
- American Academy of Child & Adolescent Psychiatry
ISIOfficial access page
Insomnia Severity Index
Perceived insomnia severity and treatment response
- Format
- Patient-reported · 7 items
- Source
- Mapi Research Trust
SCOFFOpen-access source paper
SCOFF Questionnaire
Brief eating-disorder screening
- Format
- Patient-reported or verbal · 5 questions
- Source
- Morgan, Reid & Lacey, BMJ 1999
PANSSLicensing & access
Positive and Negative Syndrome Scale
Schizophrenia symptom severity
- Format
- Clinician-rated · formal training expected
- Source
- Mapi Research Trust
Clinical documentation
Connect the score to its clinical meaning
Identify the instrument and version, who completed it, the assessment timeframe, score, interpretation, relevant item-level findings, comparison with prior scores, and how the result affected assessment or planning.
“PHQ-9 completed today: 16, consistent with moderately severe depressive symptom burden. Item 9 endorsed ‘several days’; direct suicide-risk assessment completed and documented separately.”
Last updated July 29, 2026