| 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,
|
