Suicide Risk Assessment Form - Wa Country Health Service (Wachs)

ADVERTISEMENT
PLEASE USE ID LABEL OR BLOCK PRINT
Surname
MRN
Given Name
DOB
Sex
Hospital
Address
Post Code
SUICIDE RISK ASSESSMENT
Assessment Date:
Assessment Time:
Assessment No.
SOURCES OF INFORMATION
Patient
Immediate carer (parent, spouse, child)
Other informants (family, friends)
Previous clinical records
Assessing clinician’s knowledge of Patient’s
past behaviour / current clinical presentation
Police/ambulance / other agencies
Other (please specify) _______________________________________________
Not
SUICIDALITY
SUICIDALITY
Yes
No
Yes
No
Known
(1)
(0)
(2)
(0)
Static (historical) factors
Dynamic (current) risk factor
(0.5)
Previous attempt(s) on own life
Current suicidal behaviour / attempt
Expressing hopelessness / perceived
Previous serious attempt
loss of coping or control over life
(Resulted in Hospital Admission)
(
e.g. no future plans)
Current use of drugs/alcohol
Family history of suicide
(Illicit drugs and or alcohol abuse)
Major psychiatric diagnosis
Expressing current suicidal ideas, plan
or intent
(Depression, Schizophrenia, Bi-Polar)
Recent significant life event
Major physical disability/illness
(Loss of significant other, peer group
(Chronic Pain)
member, relationship breakup)
Reduced ability to control self /
Separated/Widowed/Divorced
impulsive behaviour
(within past 12 months)
(e.g. reckless driving / damage to property)
Loss of job / retired
Expressing high level of distress
(within past 12 months)
(e.g. agitated, crying, pacing)
Absconding
History of absconding
(add 1)
Treatment refusal
(add 1)
Recent absconding attempt (add 2)
Frustration regarding hospitalisation (add 2)
Yes
No
Yes
No
Highly Changeable Mood?
Low Assessment Confidence?
Labile Affect
If yes add (2)
Minimal information from client
If yes add (1)
PROTECTIVE FACTORS:
(describe)
Religious Belief Opposing Suicide
Children / Family Member / Pet
Other - Describe____________________________________________________________________________
MANAGEMENT PLAN SUICIDE RISK
SCORE TOTAL:
HIGH
Inform treating doctor and nurse in charge immediately
Consider referral for examination by a psychiatrist at an authorised facility under the MHA
(>15)
Organise 1:1 special and maintain until assessed by Doctor or Mental Health
Review room - remove objects that may be used for suicide attempt
Organise urgent mental health assessment: response within 24 hrs - Consider contacting
RuralLink or psychiatrist on duty (as applicable)
Reassess every shift
Inform treating doctor and nurse in charge – consider admission to a secure environment
MODERATE
Initiate close visual surveillance (15 – 30 mins), observe & document behaviour
(10-14)
Review room - low stimulation, reduce ligature (hanging) points and remove projectiles
Organise mental health assessment
Reassess every 24 Hours or as deemed necessary
Continue with recommendations as made by admitting officer/ mental health consult/ liaison
MILD
Hourly Visual / Location Observation
(<9)
Reassess if required
Assessors Name:
Position Title:
Signature:
Effective: 21 August 2014
PLEASE USE ID LABEL OR BLOCK PRINT
Surname
MRN
Given Name
DOB
Sex
Hospital
Address
Post Code
SUICIDE RISK ASSESSMENT
Assessment Date:
Assessment Time:
Assessment No.
SOURCES OF INFORMATION
Patient
Immediate carer (parent, spouse, child)
Other informants (family, friends)
Previous clinical records
Assessing clinician’s knowledge of Patient’s
past behaviour / current clinical presentation
Police/ambulance / other agencies
Other (please specify) _______________________________________________
Not
SUICIDALITY
SUICIDALITY
Yes
No
Yes
No
Known
(1)
(0)
(2)
(0)
Static (historical) factors
Dynamic (current) risk factor
(0.5)
Previous attempt(s) on own life
Current suicidal behaviour / attempt
Expressing hopelessness / perceived
Previous serious attempt
loss of coping or control over life
(Resulted in Hospital Admission)
(
e.g. no future plans)
Current use of drugs/alcohol
Family history of suicide
(Illicit drugs and or alcohol abuse)
Major psychiatric diagnosis
Expressing current suicidal ideas, plan
or intent
(Depression, Schizophrenia, Bi-Polar)
Recent significant life event
Major physical disability/illness
(Loss of significant other, peer group
(Chronic Pain)
member, relationship breakup)
Reduced ability to control self /
Separated/Widowed/Divorced
impulsive behaviour
(within past 12 months)
(e.g. reckless driving / damage to property)
Loss of job / retired
Expressing high level of distress
(within past 12 months)
(e.g. agitated, crying, pacing)
Absconding
History of absconding
(add 1)
Treatment refusal
(add 1)
Recent absconding attempt (add 2)
Frustration regarding hospitalisation (add 2)
Yes
No
Yes
No
Highly Changeable Mood?
Low Assessment Confidence?
Labile Affect
If yes add (2)
Minimal information from client
If yes add (1)
PROTECTIVE FACTORS:
(describe)
Religious Belief Opposing Suicide
Children / Family Member / Pet
Other - Describe____________________________________________________________________________
MANAGEMENT PLAN SUICIDE RISK
SCORE TOTAL:
HIGH
Inform treating doctor and nurse in charge immediately
Consider referral for examination by a psychiatrist at an authorised facility under the MHA
(>15)
Organise 1:1 special and maintain until assessed by Doctor or Mental Health
Review room - remove objects that may be used for suicide attempt
Organise urgent mental health assessment: response within 24 hrs - Consider contacting
RuralLink or psychiatrist on duty (as applicable)
Reassess every shift
Inform treating doctor and nurse in charge – consider admission to a secure environment
MODERATE
Initiate close visual surveillance (15 – 30 mins), observe & document behaviour
(10-14)
Review room - low stimulation, reduce ligature (hanging) points and remove projectiles
Organise mental health assessment
Reassess every 24 Hours or as deemed necessary
Continue with recommendations as made by admitting officer/ mental health consult/ liaison
MILD
Hourly Visual / Location Observation
(<9)
Reassess if required
Assessors Name:
Position Title:
Signature:
Effective: 21 August 2014

Download Suicide Risk Assessment Form - Wa Country Health Service (Wachs)

109 times
Rate
4.6(4.6 / 5) 5 votes
ADVERTISEMENT