SBR (38)    MH TEST/SURVEY SPEC (601.712)

Name Value
INSTRUMENT SBR
LAST UPDATE 2022-04-08 08:15:55
ENTRY CHECKSUM 2906378477
ENTRY SPECIFICATION
{"name": "SBR", 
    }, 
    "choices":[
     {"id": "c2546", "text": "1. On station", "quickKey": 1}, 
     {"id": "c2547", "text": "2. Off station", "quickKey": 2}
   ]}, 
   {"id": "q5181", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "7. Patient status at time of event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
   {"id": "q5339", "type": "ChoiceQuestion", "required": true, "inline": true, 
    "columns": 3, 
    "choices":[
     {"id": "c2715", "text": "0. Veteran not in treatment", "quickKey": 0}, 
     {"id": "c2548", "text": "1. Outpatient", "quickKey": 1}, 
     {"id": "c2549", "text": "2. Inpatient", "quickKey": 2}
   ]}, 
   {"id": "q5344", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "8. Veteran status following the event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
    "text": "1. Is there any indication the Veteran engaged in self-directed violent behavior?", 
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 2, 
    "choices":[
     {"id": "c2554", "text": "1. Remained outpatient", "quickKey": 1}, 
     {"id": "c2716", "text": "2. Hospitalized (location of hospitalization: specify)", "quickKey": 2}, 
     {"id": "c2228", "text": "3. Deceased", "quickKey": 3}
   ]}, 
   {"id": "q5182", "type": "StringQuestion", "required": false, 
    "text": "8A. Hospitalized at:", 
    "intro": "Self-directed violence is behavior that is self-directed and deliberately results
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5186", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "9. Method of information:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 in injury or the potential for injury to oneself. Please note: Behavior that is
 can be determined retrospectively  ", 
    "columns": 3, 
    "choices":[
     {"id": "c2189", "text": "1. In person", "quickKey": 1}, 
     {"id": "c2188", "text": "2. Telephone", "quickKey": 2}, 
     {"id": "c2558", "text": "3. Written", "quickKey": 3}
   ]}, 
   {"id": "q5187", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "10. Source of information:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 potentially harmful (e.g. holding a  loaded gun in one's mouth) should be
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 3, 
    "choices":[
     {"id": "c2717", "text": "1. Veteran self-report", "quickKey": 1}, 
     {"id": "c2560", "text": "2. Family member", "quickKey": 2}, 
     {"id": "c2561", "text": "3. Outside agent", "quickKey": 3}, 
     {"id": "c2562", "text": "4. VA staff", "quickKey": 4}, 
     {"id": "c2718", "text": "5. Other (Specify)", "quickKey": 5}
 classified as self-directed violence.  ", 
   ]}, 
   {"id": "q5188", "type": "StringQuestion", "required": false, 
    "text": "10A. Specify \u0022Other\u0022:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5189", "type": "StringQuestion", "required": false, 
    "text": "10B. Name and phone of source:", 
    "columns": 3, 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5446", "type": "MemoQuestion", "required": false, 
    "text": "11. Last Pain Score:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
    "choices":[
 can be determined retrospectively  ", 
    "controlWidth": 510}, 
   {"id": "q5193", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "12. Did the patient have access to firearms?", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 3, 
    "choices":[
     {"id": "c237", "text": "0. No", "quickKey": 0}, 
     {"id": "c2564", "text": "0. Unknown", "quickKey": 0}, 
     {"id": "c237", "text": "1. No", "quickKey": 1}, 
     {"id": "c241", "text": "2. Yes", "quickKey": 2}
   ]}, 
   {"id": "q5345", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "13. Family and other supports available at time of the event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
 "restartDays": 0, 
     {"id": "c241", "text": "1. Yes", "quickKey": 1}
    "columns": 2, 
    "choices":[
     {"id": "c1", "text": "0. None", "quickKey": 0}, 
     {"id": "c2719", "text": "1. At least one supportive relationship", "quickKey": 1}, 
     {"id": "c2720", "text": "2. Some supportive relationships", "quickKey": 2}, 
     {"id": "c2721", "text": "3. Good social and/or family support", "quickKey": 3}, 
     {"id": "c2718", "text": "4. Other (Specify)", "quickKey": 4}
   ]}, 
   {"id": "q5346", "type": "StringQuestion", "required": false, 
    "text": "13A. Other support:", 
   ]}, 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5347", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "14. Treatment plan changes implemented due to the event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
   {"id": "i598", "type": "IntroText", 
 can be determined retrospectively  ", 
    "columns": 2, 
    "choices":[
     {"id": "c2722", "text": "0. No changes", "quickKey": 0}, 
     {"id": "c2723", "text": "1. Medication Changes (describe)", "quickKey": 1}, 
     {"id": "c2724", "text": "2. Therapy Changes (describe)", "quickKey": 2}, 
     {"id": "c2725", "text": "3. Admission to inpatient Unit", "quickKey": 3}, 
     {"id": "c743", "text": "4. Other", "quickKey": 4}
   ]}, 
   {"id": "q5356", "type": "StringQuestion", "required": false, 
    "text": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
    "text": "14A. Describe/Other:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5447", "type": "MemoQuestion", "required": false, 
    "text": "15. Past 10 clinic visits:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 510}, 
   {"id": "q5195", "type": "CheckQuestion", "required": false, "inline": false, 
    "text": "16. Patient was receiving treatment in the following area(s) at the time of this
 event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
 probable consequences of his/her actions  or potential actions. Suicidal intent
    "columns": 1, 
    "choices":[
     {"id": "c2165", "text": "0. Mental health", "quickKey": 0}, 
     {"id": "c2565", "text": "1. Substance abuse", "quickKey": 1}, 
     {"id": "c2566", "text": "2. MHICM", "quickKey": 2}, 
     {"id": "c1526", "text": "3. PTSD", "quickKey": 3}, 
     {"id": "c2567", "text": "4. Life Skills Center", "quickKey": 4}, 
     {"id": "c2568", "text": "5. HCHB", "quickKey": 5}, 
     {"id": "c2726", "text": "6. Non-VA Mental Health Care", "quickKey": 6}, 
     {"id": "c2570", "text": "7. Ambulatory care", "quickKey": 7}, 
 can be determined retrospectively  "
     {"id": "c2571", "text": "8. CBOC", "quickKey": 8}
   ]}, 
   {"id": "q5196", "type": "StringQuestion", "required": false, 
    "text": "16A. Name any specialty clinic(s) patient was receiving treatment at time of this
 event (if none, type \u0022None\u0022):", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
    }, 
   {"id": "q5448", "type": "MemoQuestion", "required": false, 
    "text": "16B. Primary Care Provider:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500}, 
   {"id": "q5352", "type": "StringQuestion", "required": false, 
    "text": "16C. Case Manager / Therapist:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
   {"id": "q5340", "type": "ChoiceQuestion", "required": true, "inline": true, 
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5353", "type": "StringQuestion", "required": false, 
    "text": "16D. Provider prescribing psychiatric medications:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "text": "2. Is or was there evidence of Suicidal Intent?", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5449", "type": "MemoQuestion", "required": false, 
    "text": "17. Active Problem List:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 510}, 
   {"id": "q5348", "type": "StringQuestion", "required": false, 
    "text": "18. Inpatient Unit at time of event:", 
 "printTitle": "Suicide Behavior Report",
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}, 
   {"id": "q5349", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "18A. Inpatient status at time of event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 that the patient wished to die, meant to kill him/herself, and understands the
 can be determined retrospectively  ", 
    "columns": 3, 
    "choices":[
     {"id": "c2550", "text": "1. On pass", "quickKey": 1}, 
     {"id": "c2551", "text": "2. Unauthorized absence", "quickKey": 2}, 
     {"id": "c2552", "text": "3. On unit", "quickKey": 3}, 
     {"id": "c2553", "text": "4. Off unit", "quickKey": 4}
   ]}, 
   {"id": "q5197", "type": "CheckQuestion", "required": false, "inline": false, 
    "text": "19. Brief Plan or Disposition (Check all that apply):", 
 probable consequences of his/her actions  or potential actions. Suicidal intent
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 1, 
    "choices":[
     {"id": "c2728", "text": " None necessary due to fatality"}, 
     {"id": "c2574", "text": " Limit the means"}, 
     {"id": "c2575", "text": " Develop a crisis management plan"}, 
     {"id": "c2729", "text": " Revise crisis management plan"}, 
 can be determined retrospectively  ", 
     {"id": "c2730", "text": " Develop specific goals and plans for the future"}, 
     {"id": "c2731", "text": " Increase social engagement"}, 
     {"id": "c2578", "text": " Decrease anxiety and agitation"}, 
     {"id": "c2579", "text": " Medication management"}, 
     {"id": "c2580", "text": " Hospitalization"}, 
     {"id": "c2581", "text": " Refer for mental health treatment"}, 
     {"id": "c2582", "text": " Provide emergency phone contact numbers"}, 
     {"id": "c2583", "text": " Assure follow-up appointment is made"}, 
     {"id": "c2732", "text": " Inform/involve someone close to Veteran of Safety Plan"}, 
     {"id": "c2585", "text": " Increase contact frequency"}
    "columns": 3, 
   ]}, 
   {"id": "q5198", "type": "StringQuestion", "required": false, 
    "text": "19A. Any other plan or disposition not list above? (If none, type
 \u0022None\u0022)", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500, "min": 0, "max": 0}], 
 "rules":[
    "choices":[
   {"question": "q5181", "operator": "NE", "value": "c2549", 
    "skips":["q5348","q5349"]}, 
   {"question": "q5187", "operator": "NE", "value": "c2718", 
    "skips":["q5188"]}, 
   {"question": "q5339", "operator": "EQ", "value": "c237", 
    "skips":["q5340","q5341","q5342","q5343","q5178","q5194","q5180","q5181",
"q5344","q5182","q5186","q5187","q5188","q5189","q5446","q5193","q5345","q5346",
"q5347","q5356","q5447","q5195","q5196","q5448","q5352","q5353","q5449","q5348",
"q5349","q5197","q5198"]}, 
   {"question": "q5340", "operator": "EQ", "value": "c237", 
     {"id": "c237", "text": "0. No", "quickKey": 0}, 
    "skips":["q5341","q5342","q5343","q5178","q5194","q5180","q5181","q5344",
"q5182","q5186","q5187","q5188","q5189","q5446","q5193","q5345","q5346","q5347",
"q5356","q5447","q5195","q5196","q5448","q5352","q5353","q5449","q5348","q5349",
"q5197","q5198"]}, 
   {"question": "q5341", "operator": "EQ", "value": "c237", 
    "skips":["q5342"]}, 
   {"question": "q5341", "operator": "EQ", "value": "c241", 
    "skips":["q5343"]}, 
   {"question": "q5344", "operator": "NE", "value": "c2716", 
    "skips":["q5182"]}, 
     {"id": "c2704", "text": "1. Undetermined", "quickKey": 1}, 
   {"question": "q5345", "operator": "NE", "value": "c2718", 
    "skips":["q5346"]}, 
   {"question": "q5347", "operator": "EQ", "value": "c2722", 
    "skips":["q5356"]}, 
   {"question": "q5347", "operator": "EQ", "value": "c2725", 
    "skips":["q5356"]}]
}
     {"id": "c241", "text": "2. Yes", "quickKey": 2}
   ]}, 
 "content":[
   {"id": "q5341", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "3. Did the behavior involve any injury?", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 3, 
    "choices":[
     {"id": "c237", "text": "0. No", "quickKey": 0}, 
     {"id": "c241", "text": "1. Yes", "quickKey": 1}
   {"id": "i597", "type": "IntroText", 
   ]}, 
   {"id": "q5342", "type": "ChoiceQuestion", "required": false, "inline": false, 
    "text": "3A. Select the most appropriate SDV behavior from this list:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 1, 
    "choices":[
     {"id": "c2705", "text": "1. Undetermined SDV, With Injury, Interrupted by Self/Other", "quickKey": 1}, 
    "text": "Self-directed violence is behavior that is self-directed and deliberately results
     {"id": "c2706", "text": "2. Undetermined SDV, With Injury", "quickKey": 2}, 
     {"id": "c2707", "text": "3. Undetermined SDV, Fatal", "quickKey": 3}, 
     {"id": "c2708", "text": "4. Suicide Attempt, With Injury", "quickKey": 4}, 
     {"id": "c2709", "text": "5. Suicide Attempt, With Injury, Interrupted by Self/Other", "quickKey": 5}, 
     {"id": "c2710", "text": "6. Suicide", "quickKey": 6}
   ]}, 
   {"id": "q5343", "type": "ChoiceQuestion", "required": false, "inline": false, 
    "text": "3B. Select the most appropriate SDV behavior from this list:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 in injury or the potential for injury to oneself. Please note: Behavior that is
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 1, 
    "choices":[
     {"id": "c2711", "text": "1. Undetermined SDV, Without Injury, Interrupted by Self/Other", "quickKey": 1}, 
     {"id": "c2712", "text": "2. Undetermined SDV, Without Injury", "quickKey": 2}, 
     {"id": "c2713", "text": "3. Suicide Attempt, Without Injury, Interrupted by Self/Other", "quickKey": 3}, 
     {"id": "c2714", "text": "4. Suicide Attempt, Without Injury", "quickKey": 4}
   ]}, 
   {"id": "q5178", "type": "StringQuestion", "required": true, "inline": true, 
 potentially harmful (e.g. holding a  loaded gun in one's mouth) should be
    "text": "4. Date and Time of event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 150, "min": 0, "max": 0}, 
   {"id": "q5194", "type": "MemoQuestion", "required": true, 
    "text": "5. Brief description of event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 classified as self-directed violence.  "
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "controlWidth": 500}, 
   {"id": "q5180", "type": "ChoiceQuestion", "required": false, "inline": true, 
    "text": "6. Location of event:", 
    "intro": "Suicidal intent: There is past or present evidence (explicit and/or implicit)
 that the patient wished to die, meant to kill him/herself, and understands the
 probable consequences of his/her actions  or potential actions. Suicidal intent
 can be determined retrospectively  ", 
    "columns": 3,