EFTA00129956

# PDS-BEMR POST SUICIDE WATCH REPORT GUIDE

<table border="1"><tr><td>Watch End Date:</td><td>Watch End Time:</td><td>AM/PM</td></tr><tr><td>Watch Conducted By:
Both Inmates &amp; Staff
Inmate
Staff</td><td colspan="2">Transferred to a Medical Center: No/Yes</td></tr></table>

## Mental Status Exam: In PDS you will be required to select a value for each of the areas below. Elaborate below.

<table border="1"><tr><td>○ Level of Consciousness</td><td>○ Psychomotor Activity</td><td>○ General Appearance</td><td>○ Behavior</td></tr><tr><td>○ Mood</td><td>○ Thought Process</td><td>○ Thought Content</td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr></table>

Narrative for Risk Factors Assessed:

EFTA00129957

Risk or Protective Factor Present

- Risk or Protective Factor Absent

0 Risk or Protective Factor Not Assessed

Mental Status Exam: In PDS you will be required to select a value for each of the areas below. You can make additional comments.

O Level of Consciousness O Psychomotor Activity O General Appearance O Behavior

O Mood O Thought Process O Thought Content

In PDS you will be required to select a value for each of the risk/dynamic/protective factors below:

<table border="1"><tr><td>+ - 0 STATIC FACTORS</td><td>+ - 0 DYNAMIC FACTORS</td><td>+ - 0 PROTECTIVE FACTORS</td></tr><tr><td>○○○ Chronic Medical Condition
○○○ Family Hx of Suicide
○○○ High Profile Crime
○○○ Hx of Childhood Abuse
○○○ Hx of Psychiatric Hospitalization
○○○ History of Mental Illness
○○○ Past Suicide Attempt
○○○ History of Violent Behavior
○○○ Lack of Family Connections
○○○ Sex Offender Status</td><td>○○○ Agitation
○○○ Current Intoxication
○○○ Current Physical Pain
○○○ Current Suicidal Ideation
○○○ Current Suicidal Intent
○○○ Current Suicidal Plan
○○○ Fear for Own Safety
○○○ Feeling Hopeless/Helpless
○○○ Feels Like a Burden
○○○ Non-Adherence to Medical Tx
○○○ Problem Solving Deficits
○○○ Recent Significant Loss
○○○ Sleeps Problems
○○○ Social Isolation
○○○ Uncontrolled Mental Health Issues</td><td>○○○ Able to Identify Reasons to Live
○○○ Adequate Problem Solving Skills
○○○ Denial of Suicidal Ideation
○○○ Future Orientation
○○○ Religious Beliefs Against Suicide
○○○ Social Support in the Institution
○○○ Supportive Family Relationships
○○○ View of Death as Negative
○○○ Willingness to Engage in Tx</td></tr></table>

Additional validated risk factors that may be relevant: Sentence >20 years; Self-harm in past month; Dual Diagnosis; Male Gender; History of Self-Injurious Behavior; Chronic/Uncontrolled Pain; No Spouse (Single, Divorced, Widowed)





EFTA00129958

Suicidal ideation is absent or is of limited frequency, intensity, duration and specificity. There are NO identifiable plans and NO associated intent. There is good self-control based on both self-report and objective assessment. There may be mild symptomatology and morbid rumination may be present. Few risk factors are present and protective factors are identified, including available and accessible social support.

Suicidal ideation is frequent with limited intensity and duration. Suicidal plans have some specificity, but NO associated intent. There is good self-control, limited to moderate symptomatology, some risk factors are present, and protective factors are identified, including available and accessible social support. Denial of ideation and intent may be present, if objective markers, such as suicide threats to others and agitation, contradict the self-report.

Frequent, intense, and enduring suicidal ideation, specific plans. Many risk factors are identified. Objective markers of risk are present (e.g., lethal method, rehearsal behaviors, saying "goodbye"); self-report of subjective intent may or may not be present. There is evidence of impaired self-control, severe symptomatology, multiple risk factors are present, and few, if any protective factors.

<table border="1"><tr><td>Present</td></tr><tr><td>Chronic Risk is present when there is a history of two or more suicide attempts</td></tr><tr><td>Absent</td></tr><tr><td>Chronic Risk is absent when there is a history of one or zero suicide attempts.</td></tr></table>

Diagnosis:

Recommendations:

EFTA00129959

Date

Progress Notes

Thanks to Christopher Bush & Scott Forbes in the development of this guide



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