SUBJECT: Suicide Risk Screening and Assessment of Individuals in State Hospitals and State-Operated Crisis Stabilization Programs

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2 DBHDD SUBJECT: Suicide Risk Screening and Assessment of Individuals in State Hospitals and State-Operated Crisis Stabilization Programs Policy: Page 2 of 3 Hospital and CSP Staff Awareness regarding Suicide Risk All direct care staff in Hospitals and CSPs (including physicians, psychologists, social workers, nurses, HSTs, Activity Therapy staff, and others as identified by the hospital or CSP) are trained to recognize the indicators of suicide risk, so that they know when to promptly take action to seek further evaluation of the consumer by professional staff. Each employee who provides direct care to consumers is responsible to inform supervisory staff if they identify any signs that a consumer is at risk of suicide or intentional self-harm so that immediate action can be taken to protect the consumer. Actions to Ensure Safety All appropriate actions are taken in order to ensure safety of the consumer and others when there is an identified risk of suicide or intentional self-harm. The actions taken correspond to level of risk and may include the following as appropriate to the specific situation: Increased level of observation Changes to treatment plan to address suicide or intentional self-harm risks Increased individual therapy, utilizing treatment methods targeted for suicidal thoughts and behavior Development of a Behavior Support Plan when such a plan would be helpful in addressing specific issues related to the suicide or intentional self-harm risk Support and encouragement from consumer peer specialist or peer mentor to encourage recovery and hopefulness Encouragement for the consumer to complete a Wellness Recovery Action Plan (WRAP) and other recovery-focused therapeutic activities In addition to these actions, ongoing monitoring of the consumer s risk of suicide or intentional self-harm is conducted by the attending physician and Hospital or CSP staff. Treatment Planning to Address Suicide Risk Specific goals and interventions are developed and included in the treatment plan for consumers identified as being at risk of self-harm. Completion of Assessment Anytime Risk is Identified by a Screening If the screening conducted at admission, at change of status, or prior to discharge determines that the person may be at risk of suicide, or if a staff member identifies a concern about risk any time during the period of treatment in the Hospital or CSP, a Suicide Risk Assessment is completed by a psychiatrist, psychologist or Advanced Practice Registered Nurse (APRN). This assessment is completed utilizing the Suicide Risk Assessment Form (Attachment B). This Suicide Risk Assessment is completed within 24 hours of the risk being identified. In the meantime, as soon as risk of intentional self-harm is identified by any staff person, appropriate precautions are taken, including but not limited to the use of a higher level of observation if necessary. The professional who completes the Suicide Risk Assessment is responsible for ensuring that the treatment team is aware of the results of the assessment. If a staff member is unable to complete the screening or assessment due to the consumer s condition at the time, the screening or assessment is completed as soon as possible after the consumer is able to respond.

3 DBHDD SUBJECT: Suicide Risk Screening and Assessment of Individuals in State Hospitals and State-Operated Crisis Stabilization Programs Policy: Page 3 of 3 Screening for Suicide Risk at Change of Status or Transition Points Risk of suicide or intentional self-harm may increase at times when the consumer s status changes in some way. The following list includes some examples of change of status or transition points that warrant screening for suicide risk: Significant change in medical status Change of status within the treatment setting (increased or decreased privileges) Hospitalization Loss of family or other support Legal status changes Initiation of discharge planning Change of hospital living unit Treatment plan changes Significant external stresses Because of the potential for increased risk, suicide screening is conducted by a physician, psychiatrist, psychologist, or APRN at times of status change; this screening is documented on Change of Status Suicide Risk Screening (Attachment C). If this screening suggests that the individual is at risk of suicide, the Suicide Risk Assessment Form (Attachment B) is completed by a psychiatrist, psychologist or APRN as noted previously in this policy. Based on the results of that Suicide Risk Assessment, all appropriate actions are taken (including postponement of discharge if necessary) to ensure safety for the consumer and others. Screening for Suicide Risk Prior to Discharge Discharge and the period immediately following discharge are times of significant transition for a consumer and therefore this creates increased risk of suicide or intentional self-harm. Identification of risk reduction strategies and specific methods to mitigate or reduce suicide risk factors is a part of discharge planning for those who have had a history of suicide risk. Prior to discharge, the attending physician repeats the screening for suicide risk for all mental health consumers, to identify potential indicators of risk. The tool for documenting this screening is the Discharge Suicide Risk Screening (Attachment D). If at the time of the discharge screening, the individual is determined to be at risk of suicide, the Suicide Risk Assessment Form (Attachment B) is completed by the psychiatrist, psychologist or APRN. Based on the results of that Suicide Risk Assessment, all appropriate actions are taken (including postponement of discharge if necessary) to ensure safety for the consumer and others. Training Attachment E Flowchart for Suicide Risk Screening and Assessment Process shows the processes described in this policy. Staff receive training in suicide risk screening and assessment, reduction of environmental factors related to suicide, and other topics related to suicide prevention. Monitoring Effectiveness of screening and assessment of suicide risk is monitored through hospital performance improvement processes.

4 ATTACHMENT A: ADMISSION ASSESSMENT FORM (Items related to Suicide and Violence Risk Screening) SUICIDE/RISK OF VIOLENCE TO SELF (check all that apply): Unable to complete screening due to consumer s mental status MENTAL STATUS: suicidal ideation Suicidal ideation expressed by pt. Suicidal intent expressed by pt. Realistic plan in community Suicidal ideation alleged by others Suicidal intent alleged by others Realistic plan in hospital DESCRIPTION OF THOUGHTS TO HARM SELF: HISTORY OF SELF HARM (especially in past six months): RISK FACTORS: HISTORICAL FACTORS: Prior suicide attempts Family hx of suicide/attempts Anniversary of major loss Impulsivity Family of origin violence Victim of physical/sexual abuse Domestic partner violence Intentional self-injurious behavior LOSS FACTORS: in voc. status of significant relationship in physical health freedom due to legal status CLINICAL FACTORS: Severely depressed Hopelessness Severe anxiety and/or agitation Anhedonia Co-morbid A&D abuse/dep. Command hallucinations Chronic pain Access to/hx of use of firearms RISK REDUCTION FACTORS: Positive social support Responsible for children < 18 y/o Sense of responsibility to family Living with another person, esp. relative DEMOGRAPHIC FACTORS: Male 65 or older 85 or older Low socioeconomic status Living alone Currently divorced Caucasian or Native American Unemployed Lack of religion/spirituality Employed Positive future orientation Eating OVERALL RISK OF VIOLENCE TO SELF: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: DBHDD Policy # Attachment A Version Page 1 of 2 ASSESSMENTS Tab

5 RISK OF VIOLENCE TO OTHERS (check all that apply): Unable to complete screening due to consumer s mental status CURRENT MENTAL STATUS: violent ideation Violent ideation expressed by pt. Violent intent expressed by pt. Realistic plan in community Violent ideation alleged by others Violent intent alleged by others Realistic plan in hospital Homicidal thoughts by the consumer DESCRIPTION OF THOUGHTS TO HARM SELF: HISTORY OF VIOLENCE (especially in past six months): Intentional infliction of harm on someone else by the consumer IMMINENT CLINICAL RISK FACTORS Agitated behavior Fear or anger Threats made face to face Specific threats Substance abuse or dependence Access to weapons Psychotic Symptoms: Paranoid or persecutory delusions Delusions associated with fear, anger, or anxiety Delusions that have been acted on before Command hallucinations to harm others OVERALL RISK OF VIOLENCE TO OTHERS: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: DBHDD Policy # Attachment A Version Page 2 of 2 ASSESSMENTS Tab

6 ATTACHMENT B: SUICIDE RISK ASSESSMENT (ADULTS) LEGAL STATUS: IST JAIL HOLD NGRI Civil Commitment Voluntary Status Marital Status: Ethnicity: Pending Charges: REASON FOR SUICIDE RISK EVALUATION (check one of the following): Follow up to Admission screening that indicated risk Follow up to Interim screening that indicated risk Follow up to Pre-Discharge screening that indicated risk SOURCES OF INFORMATION: Staff Consumer Medical Record Records t Available Family/Spouse USE THIS CHECKLIST AS A GUIDE FOR CLINICAL ASSESSMENT OF SUICIDE RISK and IDENTIFICATION OF TREATMENT PLANNING NEEDS Static Risk Factors (unchanging, historical factors - use for initial assessment only) 24 or Younger in Females 65 or Older 85 or Older Ethnicity is Caucasian Violence (History of Perpetrating) Male Substance Abuse (History of) Divorced or widowed and male Suicide ideation/threats in past, Dates: Sex Offender Previous suicide attempts (when and method): History of family of origin violence Family history of completed suicide (relationship and method): Domestic partner violence Victim of physical or sexual abuse Mental Illness History, Axis 1 Hx: Schizophrenia Bipolar MDD Acute ASPD Borderline PD Slowly Changing Risk Factors (long-term risk factors - use for initial assessment only) First prison/jail term Known new court proceedings/disciplinary actions Long or life sentence, three strikes Decrease in vocational status or unemployed Hx of poor impulse control or coping skills Loss of significant relationship Early in prison/jail term Chronic, serious, terminal, disabling or painful illness Protective custody/sensitive needs custody in jail/prison setting High risk occupation law enforcement, physician, dentist Dynamic Risk Factors (short-term risk factors - continue to assess) Suicide intent Anniversary of important loss Suicide plan Recent or impending rejection or loss Recent suicidal ideation, acute/chronic Perceived lack of support system Access to means to carry out suicidal plan Pre-death behavior e.g. note, giving things away Recent suicide attempt or self-injury Currently psychotic or has command hallucinations Well planned or highly lethal attempt / ideation Hoarding or cheeking medication Cognitive distortion Sudden calm following suicidal ideation or attempt Recent release from psychiatric hospital Recent trauma or threat to self-esteem Poor adherence with treatment or medication Recently assaultive or violent Anxious, agitated or fearful Current substance intoxication or withdrawal Disturbance of mood (depression or mania) Fearful for safety Significant current impulsivity Unstable or chaotic living situation Affective instability or lability Hopelessness or helplessness Current insomnia, poor appetite or anorexia Feelings of guilt or worthlessness Newly diagnosed with serious medical illness Withdrawal from family and friends Unexplained dramatic symptom improvement Awareness of deterioration of functional ability DBHDD Policy # Attachment B Version Page 1 of 2

7 ATTACHMENT B: SUICIDE RISK ASSESSMENT (ADULTS) Protective Factors - (check all that apply) Insight into problem Realistic life plan Exercises regularly Group activities Job assignment, security, or skills Sobriety Positive future orientation or a sense of hope Fear of suicide or death Life satisfaction Coping skills or problem solving skills Active participation in treatment / medication compliance Access to follow-up treatment (outpatient tx) or AA or NA sponsor Positive self-esteem Religious support or religious prohibition Good health Supportive family, spouse, or friends Helping others Eating Caring for a pet Fear of social disapproval Pregnancy (planned or welcomed) Stable and calm living situation Intact reality testing Caretaker or sense of responsibility to family or children SUMMARY of Evaluation of Risk Based on Above Factors, Interview of Consumer, and other information: RISK PRESENT or NO SIGNIFICANT RISK R ecommendations / Plan: Recommended LEVEL of OBSERVATION: GENERAL CONSTANT INTENSIVE Additional Recommendations: Suicide Precautions Razor Restriction Shoelace Restriction Belt Restriction Discharge to lower level of care Treatment Plan Review Intervention/Safety Plan for Discharge (complete only at discharge planning ): Caretaker instructed to restrict access to firearms Caretaker instructed to restrict access to medications Caretaker instructed to restrict access to chemicals Client to Follow-up with community provider on next business day S ee Additional Comments on: Progress te Discharge Summary Dated (required): L icensed Independent Practitioner Name/Title: Signature Date /Time DBHDD Policy # Attachment B Version Page 2 of 2

8 ATTACHMENT C: CHANGE OF STATUS SUICIDE RISK SCREENING 1. Recent History of Suicidal Symptoms or Self-destructive Behavior: YES NO a. Self-destructive behavior YES NO b. Threats YES NO c. Reports of others YES NO d. Recent or current reports of suicide ideation YES NO e. Other 2. Previous History of Self-destructive Ideation or Behavior: YES NO If, provide details: 3. Current Symptoms, Feelings, or Impulses to Act upon Thoughts of Self-Harm: YES NO 4. Suicidal Ideation: YES NO 5. Impulses to Act Self-destructively: YES NO 6. Previous Self-destructive Behavior during Treatment: YES NO 7. History of Failed, Clear Lethal Intent to Kill Self: YES NO 8. Refer for Thorough Assessment? YES NO 9. Precautions Needed Immediately to Ensure Patient Safety: Signature Name Printed Date/Time DBHDD Policy # Attachment C Version Page 1 of 1

9 ATTACHMENT D: DISCHARGE SUICIDE/VIOLENCE RISK SCREENING ADMINISTERED BY DISCHARGING PHYSICIAN PRIOR TO DISCHARGE SUICIDE/RISK OF VIOLENCE TO SELF (check all that apply): MENTAL STATUS: suicidal ideation Suicidal ideation expressed by pt. Suicidal intent expressed by pt. Realistic plan in community Suicidal ideation alleged by others Suicidal intent alleged by others Realistic plan in hospital DESCRIPTION OF THOUGHTS AND/OR PLAN TO HARM SELF: RISK FACTORS: CLINICAL FACTORS: Severely depressed Hopelessness Severe anxiety and/or agitation Anhedonia Co-morbid A&D abuse/dep. Command hallucinations Chronic pain Access to/hx of use of firearms RISK REDUCTION FACTORS: Positive social support Responsible for children < 18 y/o Sense of responsibility to family Living with another person, esp. relative DEMOGRAPHIC FACTORS: Male 65 or older 85 or older Low socioeconomic status Living alone Currently divorced Caucasian or Native American Unemployed Lack of religion/spirituality Employed Positive future orientation Eating LOSS FACTORS: in voc. status of significant relationship in physical health freedom due to legal status OVERALL RISK OF VIOLENCE TO SELF: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: RISK OF VIOLENCE TO OTHERS (check all that apply): CURRENT MENTAL STATUS: violent ideation Violent ideation expressed by pt. Violent intent expressed by pt. Realistic plan in community Violent ideation alleged by others Violent intent alleged by others Realistic plan in hospital Homicidal thoughts by the consumer DESCRIPTION OF THOUGHTS AND/OR PLAN TO HARM SELF: IMMINENT CLINICAL RISK FACTORS Agitated behavior Fear or anger Threats made face to face Specific threats Substance abuse or dependence Access to weapons Psychotic Symptoms: Paranoid or persecutory delusions Delusions associated with fear, anger, or anxiety Delusions that have been acted on before Command hallucinations to harm others OVERALL RISK OF VIOLENCE TO OTHERS: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: If the consumer is on a Jail Hold: Has jail been notified of risk? Physician s Signature Physician Name Printed Date/Time DBHDD Policy # Attachment D version Page 1 of 1 ASSESSMENTS Tab

10 Attachment E: Suicide Risk Screening and Assessment Flow Chart Person presents for admission evaluation Physician performs screening for suicide risk and documents on "Admission Assessment Form" (Attachment A) Provide appropriate levels of monitoring, support and security Moderate or high risk? Risk identified by any staff person? Physician orders appropriate "Actions to Ensure Safety" Inform appropriate supervisory staff "Suicide Risk Assessment" (Attachment B) completed by psychiatrist, psychologist, or advanced Practice Registered Nurse (APRN) within 24 hours of risk identification. Implement appropriate "Actions to Ensure Safety" Risk identified? Professional completing Risk Assessment ensures that Tx Team is aware of assessment results. Treatment Team addresses suicide risk in treatment plan Implement appropriate "Actions to Ensure Safety" Treatment Team monitors person's condition Do "Special Actions to Ensure Safety" need to continue? Risk identified? Provide appropriate levels of monitoring, support and security Physician performs screening for suicide risk and documents in the "Change of Status Suicide Risk Screening" (Attachment C). Change of status? Time for discharge? Physician performs screening for suicide risk and documents in the "Discharge Suicide Risk Screening" (Attachment D). Risk identified? Discharge DBHDD Policy Attachment E - Version

11 ATTACHMENT A: ADMISSION ASSESSMENT FORM (Items related to Suicide and Violence Risk Screening) SUICIDE/RISK OF VIOLENCE TO SELF (check all that apply): Unable to complete screening due to consumer s mental status MENTAL STATUS: suicidal ideation Suicidal ideation expressed by pt. Suicidal intent expressed by pt. Realistic plan in community Suicidal ideation alleged by others Suicidal intent alleged by others Realistic plan in hospital DESCRIPTION OF THOUGHTS TO HARM SELF: HISTORY OF SELF HARM (especially in past six months): RISK FACTORS: HISTORICAL FACTORS: Prior suicide attempts Family hx of suicide/attempts Anniversary of major loss Impulsivity Family of origin violence Victim of physical/sexual abuse Domestic partner violence Intentional self-injurious behavior LOSS FACTORS: in voc. status of significant relationship in physical health freedom due to legal status CLINICAL FACTORS: Severely depressed Hopelessness Severe anxiety and/or agitation Anhedonia Co-morbid A&D abuse/dep. Command hallucinations Chronic pain Access to/hx of use of firearms RISK REDUCTION FACTORS: Positive social support Responsible for children < 18 y/o Sense of responsibility to family Living with another person, esp. relative DEMOGRAPHIC FACTORS: Male 65 or older 85 or older Low socioeconomic status Living alone Currently divorced Caucasian or Native American Unemployed Lack of religion/spirituality Employed Positive future orientation Eating OVERALL RISK OF VIOLENCE TO SELF: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: DBHDD Policy # Attachment A Version Page 1 of 2 ASSESSMENTS Tab

12 RISK OF VIOLENCE TO OTHERS (check all that apply): Unable to complete screening due to consumer s mental status CURRENT MENTAL STATUS: violent ideation Violent ideation expressed by pt. Violent intent expressed by pt. Realistic plan in community Violent ideation alleged by others Violent intent alleged by others Realistic plan in hospital Homicidal thoughts by the consumer DESCRIPTION OF THOUGHTS TO HARM SELF: HISTORY OF VIOLENCE (especially in past six months): Intentional infliction of harm on someone else by the consumer IMMINENT CLINICAL RISK FACTORS Agitated behavior Fear or anger Threats made face to face Specific threats Substance abuse or dependence Access to weapons Psychotic Symptoms: Paranoid or persecutory delusions Delusions associated with fear, anger, or anxiety Delusions that have been acted on before Command hallucinations to harm others OVERALL RISK OF VIOLENCE TO OTHERS: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: DBHDD Policy # Attachment A Version Page 2 of 2 ASSESSMENTS Tab

13 ATTACHMENT B: SUICIDE RISK ASSESSMENT (ADULTS) LEGAL STATUS: IST JAIL HOLD NGRI Civil Commitment Voluntary Status Marital Status: Ethnicity: Pending Charges: REASON FOR SUICIDE RISK EVALUATION (check one of the following): Follow up to Admission screening that indicated risk Follow up to Interim screening that indicated risk Follow up to Pre-Discharge screening that indicated risk SOURCES OF INFORMATION: Staff Consumer Medical Record Records t Available Family/Spouse USE THIS CHECKLIST AS A GUIDE FOR CLINICAL ASSESSMENT OF SUICIDE RISK and IDENTIFICATION OF TREATMENT PLANNING NEEDS Static Risk Factors (unchanging, historical factors - use for initial assessment only) 24 or Younger in Females 65 or Older 85 or Older Ethnicity is Caucasian Violence (History of Perpetrating) Male Substance Abuse (History of) Divorced or widowed and male Suicide ideation/threats in past, Dates: Sex Offender Previous suicide attempts (when and method): History of family of origin violence Family history of completed suicide (relationship and method): Domestic partner violence Victim of physical or sexual abuse Mental Illness History, Axis 1 Hx: Schizophrenia Bipolar MDD Acute ASPD Borderline PD Slowly Changing Risk Factors (long-term risk factors - use for initial assessment only) First prison/jail term Known new court proceedings/disciplinary actions Long or life sentence, three strikes Decrease in vocational status or unemployed Hx of poor impulse control or coping skills Loss of significant relationship Early in prison/jail term Chronic, serious, terminal, disabling or painful illness Protective custody/sensitive needs custody in jail/prison setting High risk occupation law enforcement, physician, dentist Dynamic Risk Factors (short-term risk factors - continue to assess) Suicide intent Anniversary of important loss Suicide plan Recent or impending rejection or loss Recent suicidal ideation, acute/chronic Perceived lack of support system Access to means to carry out suicidal plan Pre-death behavior e.g. note, giving things away Recent suicide attempt or self-injury Currently psychotic or has command hallucinations Well planned or highly lethal attempt / ideation Hoarding or cheeking medication Cognitive distortion Sudden calm following suicidal ideation or attempt Recent release from psychiatric hospital Recent trauma or threat to self-esteem Poor adherence with treatment or medication Recently assaultive or violent Anxious, agitated or fearful Current substance intoxication or withdrawal Disturbance of mood (depression or mania) Fearful for safety Significant current impulsivity Unstable or chaotic living situation Affective instability or lability Hopelessness or helplessness Current insomnia, poor appetite or anorexia Feelings of guilt or worthlessness Newly diagnosed with serious medical illness Withdrawal from family and friends Unexplained dramatic symptom improvement Awareness of deterioration of functional ability DBHDD Policy # Attachment B Version Page 1 of 2

14 ATTACHMENT B: SUICIDE RISK ASSESSMENT (ADULTS) Protective Factors - (check all that apply) Insight into problem Realistic life plan Exercises regularly Group activities Job assignment, security, or skills Sobriety Positive future orientation or a sense of hope Fear of suicide or death Life satisfaction Coping skills or problem solving skills Active participation in treatment / medication compliance Access to follow-up treatment (outpatient tx) or AA or NA sponsor Positive self-esteem Religious support or religious prohibition Good health Supportive family, spouse, or friends Helping others Eating Caring for a pet Fear of social disapproval Pregnancy (planned or welcomed) Stable and calm living situation Intact reality testing Caretaker or sense of responsibility to family or children SUMMARY of Evaluation of Risk Based on Above Factors, Interview of Consumer, and other information: RISK PRESENT or NO SIGNIFICANT RISK R ecommendations / Plan: Recommended LEVEL of OBSERVATION: GENERAL CONSTANT INTENSIVE Additional Recommendations: Suicide Precautions Razor Restriction Shoelace Restriction Belt Restriction Discharge to lower level of care Treatment Plan Review Intervention/Safety Plan for Discharge (complete only at discharge planning ): Caretaker instructed to restrict access to firearms Caretaker instructed to restrict access to medications Caretaker instructed to restrict access to chemicals Client to Follow-up with community provider on next business day S ee Additional Comments on: Progress te Discharge Summary Dated (required): L icensed Independent Practitioner Name/Title: Signature Date /Time DBHDD Policy # Attachment B Version Page 2 of 2

15 ATTACHMENT C: CHANGE OF STATUS SUICIDE RISK SCREENING 1. Recent History of Suicidal Symptoms or Self-destructive Behavior: YES NO a. Self-destructive behavior YES NO b. Threats YES NO c. Reports of others YES NO d. Recent or current reports of suicide ideation YES NO e. Other 2. Previous History of Self-destructive Ideation or Behavior: YES NO If, provide details: 3. Current Symptoms, Feelings, or Impulses to Act upon Thoughts of Self-Harm: YES NO 4. Suicidal Ideation: YES NO 5. Impulses to Act Self-destructively: YES NO 6. Previous Self-destructive Behavior during Treatment: YES NO 7. History of Failed, Clear Lethal Intent to Kill Self: YES NO 8. Refer for Thorough Assessment? YES NO 9. Precautions Needed Immediately to Ensure Patient Safety: Signature Name Printed Date/Time DBHDD Policy # Attachment C Version Page 1 of 1

16 ATTACHMENT D: DISCHARGE SUICIDE/VIOLENCE RISK SCREENING ADMINISTERED BY DISCHARGING PHYSICIAN PRIOR TO DISCHARGE SUICIDE/RISK OF VIOLENCE TO SELF (check all that apply): MENTAL STATUS: suicidal ideation Suicidal ideation expressed by pt. Suicidal intent expressed by pt. Realistic plan in community Suicidal ideation alleged by others Suicidal intent alleged by others Realistic plan in hospital DESCRIPTION OF THOUGHTS AND/OR PLAN TO HARM SELF: RISK FACTORS: CLINICAL FACTORS: Severely depressed Hopelessness Severe anxiety and/or agitation Anhedonia Co-morbid A&D abuse/dep. Command hallucinations Chronic pain Access to/hx of use of firearms RISK REDUCTION FACTORS: Positive social support Responsible for children < 18 y/o Sense of responsibility to family Living with another person, esp. relative DEMOGRAPHIC FACTORS: Male 65 or older 85 or older Low socioeconomic status Living alone Currently divorced Caucasian or Native American Unemployed Lack of religion/spirituality Employed Positive future orientation Eating LOSS FACTORS: in voc. status of significant relationship in physical health freedom due to legal status OVERALL RISK OF VIOLENCE TO SELF: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: RISK OF VIOLENCE TO OTHERS (check all that apply): CURRENT MENTAL STATUS: violent ideation Violent ideation expressed by pt. Violent intent expressed by pt. Realistic plan in community Violent ideation alleged by others Violent intent alleged by others Realistic plan in hospital Homicidal thoughts by the consumer DESCRIPTION OF THOUGHTS AND/OR PLAN TO HARM SELF: IMMINENT CLINICAL RISK FACTORS Agitated behavior Fear or anger Threats made face to face Specific threats Substance abuse or dependence Access to weapons Psychotic Symptoms: Paranoid or persecutory delusions Delusions associated with fear, anger, or anxiety Delusions that have been acted on before Command hallucinations to harm others OVERALL RISK OF VIOLENCE TO OTHERS: ne or low, moderate risk, high risk EXPLANATION, INCLUDING ACTIONS TAKEN IF MODERATE OR HIGH RISK: If the consumer is on a Jail Hold: Has jail been notified of risk? Physician s Signature Physician Name Printed Date/Time DBHDD Policy # Attachment D version Page 1 of 1 ASSESSMENTS Tab

17 Attachment E: Suicide Risk Screening and Assessment Flow Chart Person presents for admission evaluation Physician performs screening for suicide risk and documents on "Admission Assessment Form" (Attachment A) Provide appropriate levels of monitoring, support and security Moderate or high risk? Risk identified by any staff person? Physician orders appropriate "Actions to Ensure Safety" Inform appropriate supervisory staff "Suicide Risk Assessment" (Attachment B) completed by psychiatrist, psychologist, or advanced Practice Registered Nurse (APRN) within 24 hours of risk identification. Implement appropriate "Actions to Ensure Safety" Risk identified? Professional completing Risk Assessment ensures that Tx Team is aware of assessment results. Treatment Team addresses suicide risk in treatment plan Implement appropriate "Actions to Ensure Safety" Treatment Team monitors person's condition Do "Special Actions to Ensure Safety" need to continue? Risk identified? Provide appropriate levels of monitoring, support and security Physician performs screening for suicide risk and documents in the "Change of Status Suicide Risk Screening" (Attachment C). Change of status? Time for discharge? Physician performs screening for suicide risk and documents in the "Discharge Suicide Risk Screening" (Attachment D). Risk identified? Discharge DBHDD Policy Attachment E - Version