Department(S): Patient Care Units

Department(s): Patient Care Units

Effective Date:

Policy Title: Suicide Risk Assessment

Review Dates:

Page 1 of 2

POLICY:

Policy Statement

All patients in the behavioral health unit and others being treated for emotional or behavioral disorders shall be assessed for potential suicidality.

PROCEDURE:

A.Patients in the Behavioral Health Care Unit

• The initial assessment shall include whether or not the patient is at risk for suicide.
• When the patient is found to be at risk for suicide, the interdisciplinary plan of care shall address the steps to be taken to reduce the risk and protect the patient, including the setting in which the patient receives care.
• Upon discharge the patient and involved family members shall be provided with information about suicide crisis hotlines available in the community.

B.Emergency Department Patients

• Patients whose presenting complaint is an emotional or behavioral disorder shall be assessed for suicidality.

• Patients determined to be a danger to self or others shall be cared for in a manner consistent with <STATE LAW NAME>.
• The following precautions shall be considered and implemented when deemed appropriate for patients who are a danger to themselves:
• When possible, the patient shall be placed in <LOCATION>
• Patients found to be potentially suicidal shall be closely observed. If a family member is not available to observe the patient, an employed and trained observer shall be considered.
• Psychological consultation (i.e., Psychological Evaluation Team, Psychiatrist evaluation, LCSW evaluation) should be initiated
• If patients are positively screened for suicidality and the hospital does not have a behavioral health unit, transfer to a behavioral health provider should be initiated

• Should the patient be discharged (rather than hospitalized), the patient and involved family members shall be provided with information about suicide crisis hotlines available in the community.

C.General Patient Population

• The initial nursing assessment for inpatients includes an assessment of psychosocial status.
• During that assessment, patients shall be referred to social services according to established criteria.
• Should social services find that the patient is at imminent risk for suicide, the physician shall be contacted and an appropriate treatment plan / disposition plan developed.

D.Management

• The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide.

• The patient’s immediate safety needs and most appropriate setting for treatment are addressed.
• The organization provides information such as a crisis hotline to individuals and their family members for crisis situations.

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