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3) Suicidal Thoughts with method (without Specific Plan or Intent to Act):. Person endorses thoughts of suicide and has thought of at least one method ...
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The Reading Hospital and Medical Center Sixth Avenue and Spruce Street, West Reading, PA 19611
Ask questions that are bolded and underlined. The remaining information is for staff only. Yes No
Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
General non-specific thoughts of wanting to end one's life/commit suicide, "I've thought about killing myself" without general thoughts of ways to kill oneself/associated methods, intent or plan.
Person endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place, or method details worked out. "I thought about taking an overdose but I never made a specific plan as to when, where, or how I would actually do it...and I would never go through with it. "
Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as opposed to "I have the thoughts but I definitely will not do anything about them."
Thoughts of killing oneself with details of plan fully or partially worked out, and person has some intent to carry it out.
AS
COLUMBIA-SUICIDE SEVERITY RATING SCREEN VERSION
RH2311 Revised 11.09 1 of 2
The Reading Hospital and Medical Center Sixth Avenue and Spruce Street, West Reading, PA 19611 SUICIDE IDEATION DEFINITIONS AND PROMPTS:
Ask questions that are bolded and underlined. The remaining information is for staff only. Yes No
Examples: Attempt: Took pills, shot self, cut self, jumped from a tall place; Preparation: Collecting pills, getting a gun, giving valuables away, writing a suicide or goodbye note, etc.)
II. TRHMC Response Protocol to C-SSRS Screening (Linked to last item answered YES)
Item 1 - Mental Health Referral at Discharge Item 2 - Mental Health Referral at Discharge Item 3 - Care Team Consult (Psychiatric Nurse) and Patient Safety Monitor/Procedures Item 4 - Psychiatric Consultation and Patient Safety Monitor/Procedures Item 5 - Psychiatric Consultation and Patient Safety Monitor/Procedures Item 6 - If more than a year ago, Mental Health Referral at discharge If between 1 week and 1 year ago - Care Team Consult (Psychiatric Nurse) and Patient Safety Monitor If one week ago or less - Psychiatric Consultaiton and Patient Safety Monitor
Disposition: 0 Mental Health Referral at discharge
If reassessment, please identify the stressors since initial C-SSRS assessment. If none, please write NONE in box.
1 _
Signature of Nurse/Person Completing Form Date Time
Printed Name of Nurse/Person Completing Form
AS
COLUMBIA-SUICIDE SEVERITY RATING SCREEN VERSION
RH2311 Revised 11.09 (2 of 2)