Psychosocial Distress Screening & Triage Note

(Use patient-centered, non-stigmatizing language. Keep this note focused on screening, triage, and actions—do not create a comprehensive psychiatric or social work evaluation. Separate factual data from clinical interpretation. Document uncertainty explicitly and avoid implying negatives. Include only triage-relevant content.)

Date/Time: [Date and time of documentation]

Author/Credentials: [Author name, role, and credentials]

Encounter Type: [in-person / phone / video]; [inpatient / outpatient / ED]

Reason for Screening: [routine programmatic screening / new diagnosis or treatment start / treatment transition or recurrence or progression / patient or caregiver request / clinician concern]

Data Sources: [patient self-report / caregiver / chart review / interpreter] (If interpreter used, note language and modality.)

Screening Administration

• Tool(s): [Screening instrument name and version if relevant]
• Mode: [paper / tablet or portal / interviewer-administered] (If assisted or interviewer-administered, note reason and who administered.)
• Completion Status: [completed / incomplete / not assessed] (If incomplete or not assessed, state reason. Use "Not assessed—reason:" or "Incomplete—reason:" rather than leaving blank.)
• Threshold for Positive Screen: [Local cutoff score and severity bands if used]
• Result Review with Patient: [yes / not applicable] (For positive screens, document direct contact method and date/time.)

Results & Assessment

Score: [Numeric score] — [positive / negative] per threshold (Include severity band if used.)

Primary Distress Drivers: [Top 1–3 patient-identified concerns with domains: practical / emotional / family or social / spiritual or existential / physical symptoms] (Include a brief patient quote only if it clarifies urgency or meaning.)

Safety Screen: (Required when SI, self-harm, HI, abuse/neglect concerns, or severe disorganization/psychosis is disclosed or suspected. Explicitly document presence or absence—do not use vague phrasing like "no safety concerns.")

• Suicidal Ideation (SI): [present / absent] (If present: document plan, intent, means access, past attempts, protective factors, risk level, and immediate actions taken.)
• Homicidal Ideation (HI): [present / absent] (If present: document target if identified, plan, intent, means, risk level, and actions taken.)
• Other Risk Indicators: [Abuse/neglect, non-suicidal self-harm, psychosis/disorganization—present or absent] (If present: document findings and immediate actions.)

(If no risk indicators and no concerning responses, a single confirmatory line is sufficient, e.g., "Denies SI and HI; no concerning responses observed.")

Plan

Triage Level: [Institutional triage level] (Brief rationale linked to score severity, endorsed problems, safety findings, or functional impact.)

Actions & Referrals:

• [Identified need] — [action: resource/education provided / referral placed / deferred with reason]; [destination service if referral]; [priority: routine / urgent]; [method: order / warm handoff / message]; [patient acceptance: accepted / declined]; [next step, responsible party, and timeline]
• (Repeat for each identified need. Include interventions delivered during this encounter: supportive listening, coping skills coaching, psychoeducation, symptom escalation to clinical team.)

Team Communication: [Who notified] — [method: in-person / EMR message / page / phone]

Follow-Up: [Interval], [responsible owner], [what will be reassessed], [escalation/contingency instructions] (If barriers to follow-up exist, document alternative contact plan.)

(If screen negative and no needs expressed: "Screen negative; no triage indicated. Routine rescreen at next protocol interval.")