The AHC HRSN Screening Tool, from CMS, asks 10 core questions about five needs: living situation, food, transportation, utilities, and safety. Each domain is scored on its own, and the safety answers add up to a score where 11 or more is positive. See how each domain is scored, what to do after a positive screen, and record the result with the free template. The official form comes from CMS.
For clinicians in the United States.
AHC HRSN result template
FreeAHC HRSN SCREENING RESULT Screened on: [Date] Person screened: [Name or chart number, age] Setting: [Clinic, emergency department, inpatient unit, home visit, or telehealth] Version and mode: [Standard, proxy, or multiuse form; self-completed, completed by a proxy, or read aloud by a screener] Language: [Language of the form, and any interpreter] Privacy: [Answered alone, or who was in the room] CORE DOMAINS Living situation: [Positive or negative; housing stability and condition of the home] Food: [Positive or negative; answers to the two food statements] Transportation: [Positive or negative] Utilities: [Positive or negative; shut-off threatened or service already off] Safety total: [4 to 20, with each answer 1 to 5; 11 or more is positive] Core domains positive: [0 to 5, naming each one] Not answered: [Questions skipped or declined, and any domain left undetermined] SUPPLEMENTAL DOMAINS Asked: [Which of the eight optional domains, or none] Needs found: [Positive supplemental domains, such as financial strain or loneliness] SAFETY FOLLOW-UP Urgency check: [Asked alone: safe to go home today, injuries, strangulation, weapons, children or older adults at risk] Resources given: [Hotline, advocate, shelter information, and a safe way to reach the person] Reporting: [State reporting duty considered, and what was done] HEALTH IMPACT Effect on care: [How the needs affect conditions, medicines, appointments, or self-management] REFERRALS AND ACTIONS Person's priorities: [What they want help with first, in their words] Declined for now: [Help offered and turned down] Referrals: [Agency or team, for which need, and consent to share contact details] Care plan changes: [Medicines, visit format, or follow-up changed because of a need] Z codes: [Codes recorded for positive domains, from Z55 to Z65] FOLLOW-UP Loop closure: [Who checks that each referral worked, and by when] Next screen: [Date, or within 12 months] Recorded by: [Name, role]
Use it for
Decide which domains you’ll ask and what you can offer for each one. The AHC Model required the five core domains; outside it, CMS leaves the choice to you.
Avoid: Asking about violence or housing with nowhere to send a positive answer. Plan the response before the first screen.
Most people complete it themselves, on paper or a tablet, before, during, or after the visit. A proxy can answer for a child or an adult who can’t, and a screener can read it aloud.
Avoid: Screening for safety by phone, or in the room with a partner or relative, when the person can’t speak freely.
Score each of the five domains on its own: positive, negative, or not answered. Then count the positives for the summary line.
Avoid: Reading the count as severity. One positive safety domain can matter more than three other needs together.
A total of 11 or more out of 20 is a safety need. Any report of physical harm needs an urgency check, whatever the total.
Avoid: Pushing for details before you know the person is safe right now. Safety comes first; the story can wait.
The eight optional domains are financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities. Each has its own positive rule.
Turn each positive domain into a referral the person agreed to, and check that it worked.
Each one follows the recording template. Use them to judge how much to write.
Community health center, diabetes follow-up, standard form on a tablet before the visit
Living situation: negative. Food: positive, both statements sometimes true; this pair is the Hunger Vital Sign, scored the same way, so that screen is positive too. Transportation: negative. Utilities: positive, a shut-off notice from the electric company for the 21st. Safety total 4 of 20, negative. Core domains positive: 2 of 5. Supplemental: financial strain positive.
Not needed. Given the clinic’s general safety and resource card, as every patient is.
58-year-old man with type 2 diabetes on metformin 1,000 mg twice daily and glipizide 10 mg daily. A1c 8.4%, up from 7.6% in the spring. Two lows near 60 mg/dL this month, both on days he skipped lunch to make groceries last. His warehouse hours were cut in July. He hasn’t missed his medicines.
His priority is keeping the power on. Community health worker referral accepted, for help with an energy assistance application, a payment plan with the utility, and a SNAP application; consent given to share his phone number. Given the nearest food pantry and the center’s produce days. Glipizide cut to 5 mg, taken with breakfast and skipped on any day he can’t eat. Z codes for food insecurity and difficulty paying for utilities added.
Community health worker to call him by Friday, before the shut-off date. Nurse phone check of his glucose log in 2 weeks. A1c, a second diabetes medicine if still needed, and a repeat screen in 3 months.
Family practice, new-patient visit, multiuse form on paper, completed alone in the exam room
Living situation: positive, has a place to live but worried about losing it; the lease is in her partner’s name. Food: negative. Transportation: positive, missed two appointments this year without a ride. Utilities: negative. Safety total 14 of 20: hurt 2, insult 5, threaten 3, scream 4. Positive. Core domains positive: 3 of 5.
33-year-old woman. Her partner waited in the lobby; the practice sees every adult alone for part of the visit. Says she is safe to go home today. He pushed her into a door frame in August; no injury on exam today. No strangulation, no weapon at home, no children. Threats come when he drinks and have worsened since spring. Given the hotline number, saved in her phone under a friend’s name. Agreed to a call from the local advocate on her work line. State reporting rules checked with the practice protocol: none apply, and she declined a police report.
Tension headaches and poor sleep for 6 months, worse after arguments. Overdue for cervical screening after the missed rides. Her partner knows her portal password.
Her priority is a plan to leave safely if she needs to, and keeping her job. Safety plan made with her: a bag at her sister’s, a code word, the advocate’s number. Housing: wants information only for now. Ride service set up for appointments. At her request, the safety discussion is in a confidential note her portal doesn’t show, and her printed summary covers the headaches only.
Advocate to call within 2 days, with her consent. Return in 2 weeks, booked as a headache review, with a reminder to her work line only. Safety asked again at each visit when she is alone; full screen in 12 months.
Someone hurt sometimes but never insulted, threatened, or screamed at totals 6. Any report of physical harm still needs a private urgency check the same day.
Safety and housing answers change when the person who controls them is listening. See the patient alone for part of the visit, or screen after they leave.
A referral team can’t act on a bare positive. Name each positive domain, the safety total, and what the person wants help with.
A blank leaves the domain undetermined, not negative. Record it as not answered, and offer the resources anyway.
The 0 to 5 count covers the five core domains only. Record loneliness, financial strain, and the other optional domains on their own lines.
Vero Scribe records the AHC HRSN result in your template from the visit, with the patient’s consent, or from your dictation: each core domain, the safety total, what the person wants help with, and the referrals you made. You review and edit every line, then copy it into your record. Vero works in 60+ languages.
Domain by domain. Living situation, food, transportation, and utilities are each positive when the person picks an answer that signals a need, which the official form underlines. The four safety answers score 1 to 5 each and are added; 11 or more out of 20 is positive. CMS gives no total, so this page records the number of core domains that screened positive, from 0 to 5.
A total of 11 or more, out of a range of 4 to 20. The CMS guide says any safety need should be assessed for urgency straight away, and every report of physical harm too, even with a total under 11. The National Domestic Violence Hotline answers 24 hours a day at 800-799-7233, or by text: START to 88788.
The five core domains are living situation, food, transportation, utilities, and interpersonal safety, asked in 10 questions. The eight optional supplemental domains are financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities.
Its two food questions are adapted from the Hunger Vital Sign and scored the same way, so a positive food domain matches a positive Hunger Vital Sign. The AHC tool adds housing, transportation, utilities, and safety. PRAPARE, from the National Association of Community Health Centers, is another screen across several needs; the AHC living situation and transportation questions were adapted from it.
The tool was required inside the AHC Model, which began in 2017 and has ended. For hospitals, the fiscal year 2026 inpatient payment rule, finalized July 31, 2025, removed the two social drivers of health screening measures from inpatient quality reporting, starting with the 2024 reporting period. Other programs and health plans set their own rules, so check the ones you report to.
Most people fill it in themselves. A front desk worker, medical assistant, nurse, community health worker, or social worker can hand it out or read it aloud, and CMS says any member of the care team can collect social needs data. It works in person, by phone or text before a visit, and by telehealth.
Yes, with the proxy form: a parent, guardian, or caregiver answers on the child’s behalf, and is reminded to describe the child’s situation, not their own. Some supplemental questions have age limits, and the physical activity domain can’t show a need under age 6.
In the AHC Model, people were offered the screen at least once every 12 months, and more often was allowed, since needs change. Screen again after a job loss, a move, a new baby, or a hospital stay.
Record each domain, the safety total, what you offered, and what the person chose. Social needs are coded with the ICD-10-CM Z codes from Z55 to Z65; CMS says coders can assign them from the person’s own answers or from any care team member’s note in the record.
Yes. The form, its translations, and the CMS guide are free on the CMS AHC Model page. Outside CMS, cite each question the way CMS lists, and notify the authors first for the questions that ask for it, such as the safety items. The recording template on this page is free to copy or download.
Two statements on food running out in the past 12 months: positive if either is often or sometimes true.
The two depression questions behind the supplemental mental health domain.
Goals and dated tasks for the needs the person chose to work on.
For when the clinic, a social worker, and community agencies agree one plan.
Visit notes, screening results, and referrals, recorded.
Every tool, by area, with what its scores mean.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
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