63 (63)    MH REPORT (601.93)

Name Value
REPORT NUMBER 63
INSTRUMENT SBR
RPT
.|.|Suicide Behavior Report||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: 
treatment at time of this event (if none, type "None"):|    <*Answer_5196*>|  16B.Primary Care Provider:|    <*Answer_5448*>|  16C.Case Manager / Therapist:|    <*Answer_5352*>|  16D.Provider 
prescribing psychiatric medications:|    <*Answer_5353*>|17.Active Problem List:|    <*Answer_5449*>|18.Inpatient Unit at time of event:|    <*Answer_5348*>|  18A.Inpatient status at time of event:|  
  <*Answer_5349*>|19.Brief Plan or Disposition (Check all that apply):|    <*Answer_5197*>|  19A.Any other plan or disposition not list above? (If none, type "None")|    <*Answer_5198*>|||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.>|||Questions and Answers||1.Is there any indication the Veteran engaged in self-directed violent behavior?|    
<*Answer_5339*>|2.Is or was there evidence of Suicidal Intent?|    <*Answer_5340*>|3.Did the behavior involve any injury?|    <*Answer_5341*>|  3A.Select the most appropriate SDV behavior from this 
list:|    <*Answer_5342*>|  3B.Select the most appropriate SDV behavior from this list:|    <*Answer_5343*>|4.Date and Time of event:|    <*Answer_5178*>|5.Brief description of event:|    
<*Answer_5194*>|6.Location of event:|    <*Answer_5180*>|7.Patient status at time of event:|    <*Answer_5181*>|8.Veteran status following the event:|    <*Answer_5344*>|  8A.Hospitalized at:|    
<*Answer_5182*>|9.Method of information:|    <*Answer_5186*>|10.Source of information:|    <*Answer_5187*>|  10A.Specify "Other":|    <*Answer_5188*>|  10B.Name and phone of source:|    
<*Answer_5189*>|11.Last Pain Score:|    <*Answer_5446*>|12.Did the patient have access to firearms?|    <*Answer_5193*>|13.Family and other supports available at time of the event:|    
<*Answer_5345*>|  13A.Other support:|    <*Answer_5346*>|14.Treatment plan changes implemented due to the event:|    <*Answer_5347*>|  14A.Describe/Other:|    <*Answer_5356*>|15.Past 10 clinic 
visits:|    <*Answer_5447*>|16.Patient was receiving treatment in the following area(s) at the time of this event:|    <*Answer_5195*>|  16A.Name any specialty clinic(s) patient was receiving