# Inpatient Safety Assessment

| Form ID | FRM-MHI-002 | Revision | 1.0 |
|---------|-------------|----------|-----|

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## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Date of Birth | |
| Unit/Room | |
| Admission Date | |
| Date of Assessment | |
| Time of Assessment | |
| Assessor Name | |
| Assessor Credentials | |

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## Suicide Risk Assessment

### Current Suicidal Ideation

| Question | Response |
|----------|----------|
| Are you having thoughts of suicide or self-harm? | ☐ Yes ☐ No |
| If yes, how often? | ☐ Fleeting ☐ Intermittent ☐ Persistent |
| How strong is the urge to act on these thoughts? | ☐ None ☐ Mild ☐ Moderate ☐ Strong ☐ Overwhelming |
| Do you have a plan? | ☐ Yes ☐ No |
| If yes, describe plan: | |
| Do you have access to means? | ☐ Yes ☐ No |
| Do you intend to act on these thoughts? | ☐ Yes ☐ No ☐ Ambivalent |

### Suicidal Behaviors

| Behavior | Present |
|----------|---------|
| Recent suicide attempt (within 30 days) | ☐ Yes ☐ No |
| If yes, date and method: | |
| Interrupted or aborted attempt | ☐ Yes ☐ No |
| Preparatory behaviors (writing note, giving away possessions, etc.) | ☐ Yes ☐ No |

### Historical Risk Factors

| Factor | Present |
|--------|---------|
| Previous suicide attempt(s) | ☐ Yes ☐ No |
| If yes, number and methods: | |
| Self-harm without suicidal intent | ☐ Yes ☐ No |
| Family history of suicide | ☐ Yes ☐ No |
| Previous psychiatric hospitalization | ☐ Yes ☐ No |

### Clinical Risk Factors

| Factor | Present |
|--------|---------|
| Depression | ☐ Yes ☐ No |
| Hopelessness | ☐ Yes ☐ No |
| Anxiety/agitation | ☐ Yes ☐ No |
| Psychosis | ☐ Yes ☐ No |
| Command hallucinations (self-harm) | ☐ Yes ☐ No |
| Intoxication/withdrawal | ☐ Yes ☐ No |
| Chronic pain/medical illness | ☐ Yes ☐ No |
| Recent discharge from psychiatric hospital | ☐ Yes ☐ No |
| Insomnia | ☐ Yes ☐ No |

### Precipitating Factors

| Factor | Present |
|--------|---------|
| Recent loss (relationship, job, housing) | ☐ Yes ☐ No |
| Recent humiliation/shame | ☐ Yes ☐ No |
| Legal problems | ☐ Yes ☐ No |
| Financial problems | ☐ Yes ☐ No |
| Anniversary of loss | ☐ Yes ☐ No |
| Other: | ☐ Yes ☐ No |

### Protective Factors

| Factor | Present |
|--------|---------|
| Reasons for living | ☐ Yes ☐ No |
| Future orientation | ☐ Yes ☐ No |
| Social support | ☐ Yes ☐ No |
| Religious/spiritual beliefs against suicide | ☐ Yes ☐ No |
| Responsibility for children/pets | ☐ Yes ☐ No |
| Fear of death/pain | ☐ Yes ☐ No |
| Engaged in treatment | ☐ Yes ☐ No |
| Therapeutic alliance | ☐ Yes ☐ No |

### Suicide Risk Level

☐ **Low Risk** - No current ideation, few risk factors, strong protective factors
☐ **Moderate Risk** - Ideation without plan/intent, some risk factors, some protective factors
☐ **High Risk** - Ideation with plan, intent, access to means; multiple risk factors; few protective factors
☐ **Imminent Risk** - Immediate danger, requires 1:1 observation

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## Violence/Homicide Risk Assessment

### Current Homicidal/Violent Ideation

| Question | Response |
|----------|----------|
| Are you having thoughts of hurting someone else? | ☐ Yes ☐ No |
| Is there a specific person? | ☐ Yes ☐ No |
| If yes, identify: | |
| Do you have a plan to harm this person? | ☐ Yes ☐ No |
| Do you have access to weapons? | ☐ Yes ☐ No |
| Do you intend to act on these thoughts? | ☐ Yes ☐ No |

### Historical Risk Factors

| Factor | Present |
|--------|---------|
| History of violence | ☐ Yes ☐ No |
| History of weapons use | ☐ Yes ☐ No |
| Criminal history | ☐ Yes ☐ No |
| History of impulsive behavior | ☐ Yes ☐ No |
| Childhood conduct disorder | ☐ Yes ☐ No |
| Victim of abuse/violence | ☐ Yes ☐ No |

### Clinical Risk Factors

| Factor | Present |
|--------|---------|
| Command hallucinations (violence) | ☐ Yes ☐ No |
| Paranoid delusions | ☐ Yes ☐ No |
| Manic symptoms | ☐ Yes ☐ No |
| Active substance use | ☐ Yes ☐ No |
| Medication non-adherence | ☐ Yes ☐ No |
| Lack of insight | ☐ Yes ☐ No |

### Situational Factors

| Factor | Present |
|--------|---------|
| Active interpersonal conflict | ☐ Yes ☐ No |
| Perceived threats | ☐ Yes ☐ No |
| Access to potential victims | ☐ Yes ☐ No |
| History with identified target | ☐ Yes ☐ No |

### Violence Risk Level

☐ **Low Risk** - No ideation, few risk factors
☐ **Moderate Risk** - General ideation, some risk factors
☐ **High Risk** - Specific ideation, identified target, plan, multiple risk factors

### Duty to Warn/Protect

| Field | Entry |
|-------|-------|
| Is there an identifiable potential victim? | ☐ Yes ☐ No |
| Has duty to warn been triggered? | ☐ Yes ☐ No |
| If yes, actions taken: | |
| Notification date/time: | |
| Law enforcement notified? | ☐ Yes ☐ No |
| Potential victim notified? | ☐ Yes ☐ No |

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## Self-Harm Risk Assessment

| Question | Response |
|----------|----------|
| Are you having urges to hurt yourself (without suicidal intent)? | ☐ Yes ☐ No |
| Method typically used: | |
| When did you last engage in self-harm? | |
| What triggers self-harm urges? | |
| How do you typically cope with these urges? | |

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## Elopement/AWOL Risk

| Factor | Present |
|--------|---------|
| Expressed desire to leave AMA | ☐ Yes ☐ No |
| Involuntary admission status | ☐ Yes ☐ No |
| History of elopement | ☐ Yes ☐ No |
| Agitation or restlessness | ☐ Yes ☐ No |
| External pressures to leave | ☐ Yes ☐ No |
| Poor insight into need for treatment | ☐ Yes ☐ No |

### Elopement Risk Level

☐ Low ☐ Moderate ☐ High

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## Fall Risk Assessment

| Factor | Points | Present |
|--------|--------|---------|
| Age 65+ | 2 | ☐ |
| History of falls | 3 | ☐ |
| Impaired gait/balance | 2 | ☐ |
| Psychotropic medications | 2 | ☐ |
| Sedation | 2 | ☐ |
| Confusion/disorientation | 2 | ☐ |
| Sensory impairment | 1 | ☐ |
| Toileting frequency | 1 | ☐ |
| **Total Score** | | |

**Risk Level:** ☐ Low (0-4) ☐ Moderate (5-9) ☐ High (10+)

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## Assigned Precautions

### Observation Level

☐ 1:1 Continuous (within arm's reach)
☐ 1:1 Visual (constant visual)
☐ Close observation (q5-15 min)
☐ Routine observation (q15-30 min)
☐ Open

### Additional Precautions

| Precaution | Ordered |
|------------|---------|
| Suicide precautions | ☐ |
| Self-harm precautions | ☐ |
| Violence precautions | ☐ |
| Elopement precautions | ☐ |
| Fall precautions | ☐ |
| Seizure precautions | ☐ |
| Aspiration precautions | ☐ |
| Assault precautions | ☐ |

### Environmental Modifications

☐ Safety room (ligature-resistant)
☐ Remove sharps from access
☐ Remove potential ligature materials
☐ Supervised shaving
☐ Supervised meals (plastic utensils)
☐ Other: _____________

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## Plan

**Immediate Safety Interventions:**

**Recommended Observation Level:**

**Rationale for Level:**

**Reassessment Schedule:**
☐ Every shift
☐ Daily
☐ Other: _____________

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## Physician Review

| Field | Entry |
|-------|-------|
| Physician Name | |
| Date/Time Reviewed | |
| Agrees with Assessment | ☐ Yes ☐ No |
| Orders Modified? | ☐ Yes ☐ No |
| Modifications: | |
| Signature | |

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## Reassessment Log

| Date/Time | Assessor | Risk Level Change | New Observation Level | Signature |
|-----------|----------|-------------------|----------------------|-----------|
| | | ☐ Yes ☐ No | | |
| | | ☐ Yes ☐ No | | |
| | | ☐ Yes ☐ No | | |
| | | ☐ Yes ☐ No | | |

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*Form FRM-MHI-002 Rev 1.0 - Inpatient Safety Assessment*