Psychiatry
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[date name="variable_1" default="02/05/2021"]
(1) Risk Factors(Note those that can be modified to reduce risk)
Suicidal Behavior
[checklist name="variable_1" value="None|Past attempts|Aborted attempts| Rehearsals | Self-Harm"]
Current/Past Psychiatric Diagnoses and Treatment
[textarea name="variable_1" default="sample text"]
Key Symptoms
[checklist name="variable_1" value="Anhedonia|Impulsivity|Hopelessness|Anxiety|Panic Attacks|Global Insomnia|Command Hallucinations"]
Family History of Suicidal Behavior
[checklist name="variable_1" value="None|History includes"]
[textarea name="variable_1" default="sample text"]
Change in Treatment
[checklist name="variable_1" value="Academic|Family|Relationship or Social|Reputational|Vocational|Major Loss|Major Trauma|Financial|Legal"]
Risk Behaviors
[checklist name="variable_1" value="None|Substance Abuse|Alcohol|Self-Harm|Inappropriate Sexual Behavior"]
Access to Weapons, sharps,meds(RX/OTC)
(2) Protective Factors (Note those that can be enhanced)
Internal
[checklist name="variable_1" value="Ability to Cope with Stress|Religious Beliefs|Fustration Tolerance|Absence of Psychosis"]
External
[checklist name="variable_1" value="Responsibility to family or pets|Positive Therapeutic Relationships|Social Supports"]
(3) Suicide Inquiry(suicidal thoughts, plans, behavior, and intent)
Ideation

Frequency
[select name="variable_1" value="Last 48 Hours____________
|Past Month_____________|Worse Ever______________"]
Intensity
[select name="variable_1" value="Last 48 Hours____________
|Past Month_____________|Worse Ever______________"]
Duration
[select name="variable_1" value="Last 48 Hours____________
|Past Month_____________|Worse Ever______________"]
Current Plan
[checklist name="variable_1" value="None|Timing|Location|Lethality|Availability|Preparatory"]
Behaviors
[checklist name="variable_1" value="None|Past Attempts|Aborted Attempts|Rehearsals|Self-Harm"]
Current Intent
[checklist name="variable_1" value="None|Expects to Carry out Plan|Believes Plan is Lethal|Believes Plan is Self-Injuries"]
Reason to Die
[text name="variable_1" default="sample text"]
Reasons for Live
[text name="variable_1" default="sample text"]

RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS

Risk/Protective Factors
[select name="variable_1" value="High-Psychiatric diagnoses with severe symptoms or acute precipitating event;protective factors not relevant|Moderate Multiple risk factors, few protectivefactors|Low Modifiable risk factors, strong protective factors"]

Suicidality
[select name="variable_1" value="High-Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal| Moderate-Suicidal ideation with plan, but no intent or behavior|Low-Thoughts of death, no plan, intent, or behavior"]

Possible Interventions
[select name="variable_1" value="High-Admission generally indicated unless a significant change reduces risk. Suicide precautions|Moderate-Admission may be necessary depending on risk
factors. Develop crisis plan. Give emergency/crisis
numbers|Low-Outpatient referral, symptom reduction.
Give emergency/crisis numbers"]

(5)Document Treatment Plan
Risk/Protective Factors
[checklist name="variable_1" value="High|Moderate|Low"]
Suicidality
[checklist name="variable_1" value="High|Moderate|Low"]
Intervention Level
[checklist name="variable_1" value="High|Moderate|Low"]

Medications
[textarea name="variable_1" default="sample text"]

Suicide Precautions Advised
[select name="variable_1" value="Daily close monitoring and supervision|Ongoing consistent contact with safe individuals|restrict access to weapons(including firearms, knives, ropes, dangerous machinery) and medications(RX and OTC)|Counseled on supportive strategies to ensure safety and minimize conflict while arranging for further assessment or monitoring for response to treatment."]

Suicide Plan Provided
[textarea name="variable_1" default="sample text"]

Crisis Plan Developed with Patient
[textarea name="variable_1" default="sample text"]

(1) Risk Factors(Note those that can be modified to reduce risk)
Suicidal Behavior

Current/Past Psychiatric Diagnoses and Treatment

Key Symptoms

Family History of Suicidal Behavior


Change in Treatment

Risk Behaviors

Access to Weapons, sharps,meds(RX/OTC)
(2) Protective Factors (Note those that can be enhanced)
Internal

External

(3) Suicide Inquiry(suicidal thoughts, plans, behavior, and intent)
Ideation

Frequency

Intensity

Duration

Current Plan

Behaviors

Current Intent

Reason to Die

Reasons for Live


RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS

Risk/Protective Factors


Suicidality


Possible Interventions


(5)Document Treatment Plan
Risk/Protective Factors

Suicidality

Intervention Level


Medications


Suicide Precautions Advised


Suicide Plan Provided


Crisis Plan Developed with Patient

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