mental-health-inpatient/Forms/Assessment-Tools/FRM-MHI-002-Safety-Assessment.md

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