Measuring the patient: GAF, PHQ-9, GAD-7, C-SSRS, MSE

A WC behavioral-health record has to show movement objectively, not just narratively. Standardized instruments give the case its measurable spine — the same numbers the clinician uses to guide care also demonstrate to reviewers that treatment is working.

The GAFGlobal Assessment of Functioning — a 1–100 composite of symptom severity and social and occupational functioning is the broadest measure. It is captured at four timepoints: pre-injury, initial, current (often per session), and final. It is a composite of symptom severity together with social and occupational functioning, and it is scored to the worst of those three domains — a person functioning well socially but severely impaired occupationally is rated by the impairment, not the strength.

The PHQ-9a 0–27 self-report depression measure tracks depression on a 0–27 scale, with bands of 0–4 none, 5–9 mild, 10–14 moderate, 15–19 moderately severe, and 20–27 severe. Two features matter beyond the total. Item 9 screens suicidal ideation, and any positive endorsement triggers a mandatory C-SSRS follow-up — the score is never read in isolation from that safety check. And a change of ≥5 points is considered a reliable change rather than measurement noise, which is the benchmark for "is this patient actually moving."

The GAD-7a 0–21 self-report anxiety measure tracks anxiety on a 0–21 scale. The C-SSRSthe Columbia-Suicide Severity Rating Scale, used to assess suicide risk is the structured suicide-risk assessment that PHQ-9 Item 9 hands off to. The MSEthe Mental Status Exam — the structured objective clinical findings the regulations require records the objective examination findings the regulations expect in the report.