Self Harm/Suicide Assessment Refresher

When working with patients enrolled in a behavioral health protocol, when does the nurse assess for suicidal thoughts, plans or intent?

Admission/first outpatient visit

When clinically indicated or as indicated by protocol

Frequency is determined by current risk level or change in patient condition

Prior to leaving/returning from therapeutic outing

In preparation for discharge

All of the above

Which statement is TRUE about the difference between a medical-surgical/self harm risk screening and a behavioral health suicide/self harm assessment?

Both are required for all inpatients at the Clinical Center

Everyone on the inpatient behavioral health unit is high risk

The Med/Surg Screening conducted is a simple 4 question tool. A positive response would indicate the need for further evaluation by social work/Psychiatry. The Behavioral Health unit Assessment is extensive and includes specific thoughts/plans

A Nurse Practitioner or MD assigns the patient risk level on the Behavioral Health Unit

At this risk level, the patient denies suicidal thoughts. Reassessment is conducted whenever there is a change in patient's condition or an escalation risk

High Acute

High Chronic

Medium

Low

At this risk level, patient report passive suicidal ideation with no intent or plan, reassessment occurs at least every 24 hours and whenever there is a change in escalation risk

High Acute

High Chronic

Medium

Low

At this risk level, the patient reports ongoing chronic thoughts of self harm with no current plan or intent. Reassessment occurs twice daily (once on day shift once on evening shift)

High Acute

High Chronic

Medium

Low

At this risk level, the patient reports imminent intention and/or plan or is exhibiting impulsive behaviors. Reassessments occur at least twice daily

High Acute

High Chronic

Medium

Low