Suicide Assessment
Level of Suicide Precaution Interventions
Nursing Procedure for Suicide Precautions
100

Memorial's four levels of suicide risk.

What are Low, Moderate-low, Moderate high, and High?

100

Immediately complete an environmental sweep of potentially dangerous items is initiated.

What is Moderate to High-Risk Interventions?

200

Purpose of the behavior has a least some intent to die, could kill someone, and was so highly lethal that no other inference could be made.

What is Suicidal Behaviors?

200

1:1 observation by staff member, documentation every 15 minutes.

What is high-risk interventions?

200

Family cannot be utilized for this role.

What is a sitter or observer?

300
Purpose of the behavior is not to die, not to kill, and not certainty the behavior will cause death.

What is Non-suicidal, Self-injurious behavior?

300

Notify the provider, provide patient with National Suicide Prevention Lifeline number, and initiate referrals, consults, and out-patient resources as necessary.

What is low-risk suicide precations?

400

This is initiated when a patient presents as a danger to themselves or others, makes an overt attempt, verbalized intent to do harm to themselves, or screens Moderate-high or High risk.

What is suicide precautions?

400
Include precautions in nursing handoff is initiated.

What is moderate to low-risk interventions?

400

Suicide precautions can be initiated by an RN in this type of situation.

What is an emergent situation?

500

All patients are screened for suicide risk by asking the the BOLD and underlined questions of this screening tool. The questions answered YES determine the patient's risk for suicide. 

What is the Columbia Suicide Severity Rating Scale (CSSRS)? 

500

Provider may schedule patient to follow-up for counselling/outpatient treatment and high-risk suicide precautions must be discontinued.

What is interventions for discharge of patient?