| 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
|
