Initial Screening & Admission
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What was the diagnosis upon admission?
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Was a suicide risk screening completed at the time of admission?
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Risk Level Identified?
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Screening tool used?
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Was a medical screening, including triage vitals and any necessary medical treatments, completed?
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Were any acute medications administered to stabilize the patient (if applicable)?
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Was the patient medically cleared?
Legal & Safety Protocols
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Was a Notice of Emergency Detention and Application for Examination (MC 105) filed if the patient was considered a risk to self or others?
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Was the patient provided with their rights documentation (MC 404)?
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Were safety precautions implemented based on the risk level?
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Observation level
Environmental Safety Measures
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Were the patient’s belongings searched and safely stored?
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Was the patient placed in a purple gown (or designated safety gown) per protocol for those on involuntary hold?
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Were all personal belongings (including clothing, shoes, and accessories) secured to prevent self-harm?
Ongoing Monitoring & Clinical Evaluation
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Was Psychiatric Emergency Services (PES) contacted for evaluation once the patient was medically cleared?
- Yes, Referral Placed
- Yes- Unsure of notification method
- No
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Was the patient evaluated by a PES clinician within the required 2-hour window?
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Were daily re-evaluation notes completed (if patient remained on institutional hold) to document the continued need for safety hold?
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Was the patient’s observation level re-assessed and documented regularly?
Interventions & Follow-Up
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Were behavioral interventions, including counseling or therapy, provided to address the patient’s suicidal ideation?
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Was a suicide risk reassessment performed prior to discharge?
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Was a safety plan created and documented before discharge?
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Was a post-discharge follow-up plan (e.g., outpatient counseling, crisis intervention) scheduled and documented?
Compliance & Documentation Review
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Are all required documentation (suicide risk screening, interventions, observation, discharge planning) completed and accurate?
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Was the care and management of the patient consistent with hospital policy for suicide risk patients?
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Comments/Notes about compliance:
