Risk assessment documentation: What clinicians need to know
Remote monitoring tools, like the PHQ-9, can be an effective way to track client progress, adjust treatment plans, identify growth opportunities, and ensure payer compliance. In this guide to digital client tracking, we break down which tools are most effective and offer tips for compliance, consent, and more.
What are remote monitoring tools?
Remote monitoring tools are automated measurement-based care systems used by providers to streamline digital client tracking, helping clinicians monitor symptoms and treatment progress over time.
Patient Health Questionnaire (PHQ-9): One of the most common screening tools for depression used by a range of providers in primary care and other clinical settings.
Generalized Anxiety Disorder 7-item screening (GAD-7): A seven-item scale used to screen for anxiety.
Post-Traumatic Stress Disorder Checklist (PCL-5): A 20-item self-report questionnaire to screen for PTSD symptoms over the past month.
Other measures include:
Mood logs: Clients use mood trackers to monitor symptoms of mood disorders, like bipolar disorder, and track helpful information such as sleep, medication, and exercise.
Symptom management worksheets: Like mood logs, these symptom trackers can help clients self-manage their mental health by monitoring symptoms and other helpful information.
Sleep diary templates: These templates help clients monitor sleep patterns and habits to improve sleep hygiene.
Which tools are most effective for remote monitoring?
Research shows that measures like the GAD-7, PCL-5, and PHQ-9 are quick, effective, valid, and reliable tools to screen for symptoms of anxiety and depression. They can be particularly effective in settings like primary care, where time is limited and mental health conditions may otherwise be missed.
From a clinician's perspective, using these instruments for digital client tracking provides valuable clinical insights while fulfilling payers' obligations to track progress.
However, results from these monitoring tools often lack context, such as the stressors in the client’s life at the time of testing. For example, a client may be late to their appointment, just had a conflict at work with their boss, and feel more hopeless than usual.
It’s also important to consider taking these measures at regular intervals to provide more reliable information over time.
When determining what tools are most effective for your practice, research shows that measures like the GAD-7, PCL-5, and PHQ-9 offer quick, valid, and reliable symptom tracking.
How to use data from remote monitoring tools
Understanding how to use data collected from measurement tools allows clinicians to tailor treatment interventions and objectively track clinical progress. Data from remote monitoring tools can be used in several ways, including:
Evaluate for risk of suicide: Symptom severity on measures like the PHQ-9 may indicate the need to screen for suicidal ideation and may highlight the need to develop a safety plan.
Refer to other providers: High scores on measures may indicate the need for medical or therapeutic care outside of your scope. For example, a client with severe depression may also benefit from medical intervention. Or, a client with trauma may benefit from a different intervention than you offer, like EMDR.
Evaluate readiness for discharge: Information from these measurements can be used to track the client’s overall progress during 6 to 12 months of treatment. For instance, a significant reduction in symptom severity and in daily functioning indicates that the client is achieving their treatment goals and may be discharged.
Justify medical necessity: Data gathered from remote monitoring tools can be used to support treatment recommendations and frequency of visits with insurance payers.
Address deeper issues: Context matters. Data from these self-reports can be used to better understand the client and the stressors they face, and to identify opportunities to strengthen the client’s coping strategies or gain new perspectives on their challenges.
When to implement remote monitoring tools
Tracking tools can be used at any time. However, clinicians may find remote monitoring tools most effective when completed as part of the client’s intake paperwork to help them identify symptom severity, inform treatment planning, and track progress throughout treatment.
Some EHRs allow you to send digital client tracking questionnaires electronically, and you can even set up automated measures once a month. Research shows that if measures are compatible with smartphones, clients may be more likely to engage with remote monitoring tools, leading to more accurate progress data.
If you are wondering when to implement tracking measures, starting during the intake process provides a baseline to monitor symptoms throughout treatment.
What about security with digital client tracking?
As remote monitoring tools may contain protected health information, it’s important to ensure that providers implement security measures to keep data safe and prevent breaches. Using HIPAA-compliant platforms, such as an EHR, provides end-to-end encryption, multi-factor authentication, access controls, and secure data storage.
If using third-party apps or remote monitoring tools to track client progress, you’ll have to verify their HIPAA compliance before implementing.
How to ensure compliance in remote monitoring
Depending on the type of clinical services provided and which insurance company you are paneled with, payers may require regular progress monitoring, and some allow you to bill for it.
When adopting remote monitoring tools, be sure to check the fine print of the insurance you are paneled with to understand their specific requirements. Examples of compliance requirements include obtaining informed consent from clients and ensuring HIPAA compliance and data security.
Knowing how to ensure compliance requires reviewing your specific payer contracts for mandatory tracking and documentation guidelines.
The American Medical Association and the Centers for Medicare and Medicaid Services (CMS) allow certain providers to bill for non-physiological tracking, called remote therapeutic monitoring (RTM). Eligibility to bill RTM codes varies by license type and is still evolving under CMS's 2026 rule changes, so check current payer policy before billing.
While data is usually collected through medical devices, CMS recently expanded options for digital client tracking to include non-physiological data, such as symptom and mood tracking, anxiety and depression symptoms, medication compliance, sleep data, stress levels, and therapy adherence.
What about client consent?
Before introducing remote monitoring tools, clients must be informed how their data is used, what it is used for, who has access to it, how it is stored, their right to opt out, and how to obtain their data before signing consent.
Sources
Centers for Medicare & Medicaid Services. (2025). Telehealth & remote monitoring.
Choudhary, S., Thomas, N., Ellenberger, J., Srinivasan, G., & Cohen, R. (2022). A machine learning approach for detecting digital behavioral patterns of depression using nonintrusive smartphone data (complementary path to Patient Health Questionnaire-9 assessment): Prospective observational study. JMIR Formative Research.
Guttman, M. E. (2023). Rethinking how we measure progress in mental health treatment. National Alliance on Mental Illness.
Owings-Fonner, N. (2019). Research roundup: Monitoring treatment progress. American Psychological Association.
Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus.
Siniscalchi, K. A., Broome, M. E., Fish, J., Ventimiglia, J., Thompson, J., et al. (2020). Depression screening and measurement-based care in primary care. Journal of Primary Care & Community Health.
Torous, J., Staples, P., Shanahan, M., Lin, C., Peck, P., et al. (2015). Utilizing a personal smartphone custom app to assess the Patient Health Questionnaire-9 (PHQ-9) depressive symptoms in patients with major depressive disorder. JMIR Mental Health.
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