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, |