| RPT |
.| .| Suicide Behavior Report| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
15. Inpatient unit at time of event:| <*Answer_6728*>| 15A. Inpatient status at time of event:| <*Answer_6729*>| 16. Brief Plan or Disposition (Check all that apply):|
<*Answer_6730*>| 16A. Any other plan or disposition not listed above? (If none, type "None")| <*Answer_6731*>| 17. Is there any indication that the person engaged in self-directed violent
behavior, either preparatory or potentially harmful?| <*Answer_6697*>| 18. Is there any indication that the person had self-directed violence related thoughts?| <*Answer_6698*>| 18A.
Were/Are the thoughts suicidal?| <*Answer_6699*>| 19. Did the behavior involve any injury?| <*Answer_6700*>| 19A. Was the injury fatal?| <*Answer_6701*>| 19B. Was the behavior
preparatory only?| <*Answer_6702*>| 19C. Was the behavior interrupted by self or other(s)?| <*Answer_6703*>| 20. Is there evidence of suicidal intent?| <*Answer_6704*>| | |
Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in
conjunction with other diagnostic activities and procedures.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Date and Time of event:| <*Answer_6705*>| 2. Brief description
of event:| <*Answer_6706*>| 3. Location of event::| <*Answer_6707*>| 4. Veteran status at time of event:| <*Answer_6708*>| 5. Veteran status following the event:|
<*Answer_6709*>| 5A. Hospitalized at:| <*Answer_6710*>| 6. Method of information:| <*Answer_6711*>| 7. Source of information:| <*Answer_6712*>| 7A. Specify "Other"|
<*Answer_6713*>| 7B. Name and phone of source:| <*Answer_6714*>| 8. Last Pain Score:| <*Answer_6715*>| 9. Did the veteran have access to firearms?| <*Answer_6716*>| 10. Family
and other supports available at time of event:| <*Answer_6717*>| 10A. Other support:| <*Answer_6718*>| 11. Treatment plan changes implemented due to the event:| <*Answer_6719*>|
11A. Describe / Other| <*Answer_6720*>| 12. Past 10 clinic visits:| <*Answer_6721*>| 13. Veteran was receiving treatment in the following area(s) at the time of this event:|
<*Answer_6722*>| 13A. Name any specialty clinic(s) veteran was receiving treatment at time of this event (if none, type "None"):| <*Answer_6723*>| 13B. Primary Care Provider:|
<*Answer_6724*>| 13C. Case Manager / Therapist:| <*Answer_6725*>| 13D. Provider prescribing psychiatric medications:| <*Answer_6726*>| 14. Active Problem List:| <*Answer_6727*>|
|
