| RPT |
| | Columbia Suicide Severity Rating Scale (C-SSRS) | |
|<*Answer_7774*>||
Questions and Answers: ||
1. Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?| <*Answer_7801*>|
2. Over the past month, have you had any actual thoughts of killing yourself? | <*Answer_7802*>|
3. Over the past month, have you been thinking about how you might do this? | <*Answer_7803*>|
4. Over the past month, have you had these thoughts and had some intention of acting on them? | <*Answer_7804*>|
5. Over the past month, have you started to work out or worked out the details of how to kill yourself?| <*Answer_7805*>|
6. If yes, at any time in the past month did you intend to carry out this plan?| <*Answer_7806*>|
7. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills,
obtained a gun, gave away valuables, went to the roof but didn't jump)?| <*Answer_7807*>|
Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.> |
8. If yes, was this within the past 3 months?| <*Answer_7808*> ||
| |Columbia-Suicide Severity Rating Scale (C-SSRS) 2016 The Columbia Lighthouse Project. Scale may be reproduced without permission.
| |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. $~
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Gender: <.Patient_Gender.> | |
| Suicidal Ideation in Past Month: <*Answer_7771*>|
| Method/Plan/Intent in Past Month: <*Answer_7772*>|
| Suicidal Behavior: <*Answer_7773*>||
| KEY INDICATORS:
|
