1.4 Patient Screenings & Wellness Assessments
Key Takeaways
- The USPSTF recommends biennial screening mammography for women aged 40 to 74 (Grade B, finalized April 2024), colorectal cancer screening beginning at age 45 through 75, and annual low-dose CT lung screening for adults 50 to 80 with a 20 pack-year history who currently smoke or quit within the past 15 years.
- The PHQ-2 is a two-item depression pre-screen; a positive result triggers the nine-item PHQ-9, which is scored 0 to 27 with severity cut points at 5 (mild), 10 (moderate), 15 (moderately severe), and 20 (severe).
- PHQ-9 item 9 asks about thoughts of self-harm; any nonzero response requires immediate escalation to the provider before the patient leaves the office, never routine routing to a message queue.
- Screen for intimate partner violence with the patient alone in the room, never in the presence of a partner, family member, or friend acting as interpreter.
- DEXA bone densitometry is the standard osteoporosis screening test; a T-score of -2.5 or lower is diagnostic of osteoporosis and -1.0 to -2.4 indicates osteopenia.
Why Screening Is Its Own Competency
Screening tests asymptomatic people to detect disease or risk early; diagnostic testing evaluates a patient who already has symptoms or an abnormal screen. The distinction matters clinically and financially — a screening colonoscopy and a diagnostic colonoscopy carry different Current Procedural Terminology (CPT) codes and different patient cost-sharing, and mislabeling one as the other is a common source of denied claims.
The medical assistant's role in screening is protocol-driven. You administer the instrument exactly as validated, score it by the published rules, document the numeric result, and route it according to the practice's standing orders. You do not interpret the score into a diagnosis and you do not decide independently that a positive screen can wait.
Cancer and Bone Density Screening Intervals
| Screening | Current USPSTF guidance | Modality |
|---|---|---|
| Breast cancer | Biennial, women aged 40–74 (Grade B, 2024) | Screening mammography |
| Cervical cancer | Ages 21–29 cytology every 3 years; 30–65 cytology every 3 years, or high-risk HPV testing every 5 years, or co-testing every 5 years | Pap test / HPV test |
| Colorectal cancer | Begin at age 45 through 75 (45–49 Grade B, 50–75 Grade A) | Colonoscopy every 10 years, or annual fecal immunochemical test (FIT), or stool DNA-FIT every 1–3 years |
| Lung cancer | Annual, ages 50–80 with a 20 pack-year history, currently smoking or quit within 15 years | Low-dose computed tomography (LDCT) |
| Osteoporosis | Women aged 65 and older, and younger postmenopausal women at increased risk | DEXA (dual-energy x-ray absorptiometry) |
Pack-years are calculated as packs smoked per day multiplied by years smoked. A patient who smoked one and a half packs daily for 16 years has 24 pack-years and meets the LDCT threshold.
T-scores from DEXA compare the patient to a healthy young adult reference. A T-score at or above -1.0 is normal, -1.1 to -2.4 is osteopenia, and -2.5 or lower is osteoporosis.
Sexually Transmitted Infection Screening
Annual chlamydia and gonorrhea screening is recommended for all sexually active women under 25 and for older women at increased risk. Everyone aged 15 to 65 should be screened at least once for human immunodeficiency virus (HIV), and hepatitis C screening is recommended once for all adults aged 18 to 79. Because these results are frequently subject to heightened state confidentiality protections, route them through the provider rather than releasing them directly to a caller.
Tobacco and Substance Use
The 5 A's structure tobacco cessation counseling: Ask about use at every visit, Advise quitting in a clear personalized message, Assess willingness to attempt quitting, Assist with pharmacotherapy and counseling referral, and Arrange follow-up. First-line pharmacotherapy includes nicotine replacement (patch, gum, lozenge), bupropion, and varenicline.
Substance use screening in primary care commonly uses the CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener — two or more affirmative answers is a positive screen) or the AUDIT-C for alcohol specifically. The SBIRT model — Screening, Brief Intervention, and Referral to Treatment — is the framework that connects a positive screen to action.
A 62-year-old patient with a 30 pack-year smoking history who quit 8 years ago asks whether she qualifies for lung cancer screening. According to current USPSTF guidance, what should the medical assistant document and route to the provider?
Depression and Suicide Screening
The PHQ-2 asks two questions covering depressed mood and anhedonia over the prior two weeks, each scored 0 to 3 for a total of 0 to 6. A score of 3 or higher is positive and triggers the full PHQ-9.
The PHQ-9 adds seven items for a total possible score of 27:
| PHQ-9 total | Severity |
|---|---|
| 0–4 | Minimal |
| 5–9 | Mild |
| 10–14 | Moderate |
| 15–19 | Moderately severe |
| 20–27 | Severe |
Item 9 is the safety item. It asks about thoughts of being better off dead or of hurting oneself. Any response other than "not at all" — even a total score in the minimal range — requires that you notify the provider immediately, before the patient leaves the building. This is the single most heavily tested point in ambulatory depression screening: the correct action is direct, in-person escalation, never a routine electronic message or a callback scheduled for the next business day.
Intimate Partner Violence Screening
The USPSTF recommends screening women of reproductive age for intimate partner violence. Validated brief tools include HITS (Hurt, Insult, Threaten, Scream) and HARK.
The procedural rules are as important as the instrument:
- Screen the patient alone. If a partner, adult child, or friend will not leave, defer the screen and document why rather than asking in their presence.
- Never use an accompanying family member as the interpreter for a violence screen.
- Do not print or hand the patient written referral material they must carry out past a waiting partner unless they ask for it.
- A disclosure of current danger is escalated immediately; mandatory reporting obligations vary by state and by whether a child, elder, or dependent adult is involved.
Documenting Screening Results
Record the instrument name, the numeric score, the date, and the disposition — for example, "PHQ-9 administered 08/29/2026, score 14 (moderate), provider notified, item 9 scored 0." A screening result recorded as "positive" without the score is not usable for tracking response to treatment and will not support the quality measures the practice reports.
A patient completes a PHQ-9 with a total score of 6, which falls in the mild range. Item 9 is scored 1 ("several days" of thoughts that she would be better off dead). What is the medical assistant's correct action?
A medical assistant is preparing to administer an intimate partner violence screen. The patient's husband is in the examination room and declines to step out, offering to help translate because the patient speaks limited English. What is the appropriate action?