D.18 MCM PC-110 High Risk for Suicide Patient Record Flags.pdf

Butler VA Health Care System Medical Center Memorandum PC-110 Butler, PA November 25, 2019

HIGH RISK FOR SUICIDE PATIENT RECORD FLAGS (HRS-PRF)

I. PURPOSE: The Suicide Prevention Coordinator (SPC), in conjunction with the Suicide Risk Reduction Team (SRRT) as well as any other appropriate members of the Veteran’s treatment team, determines if Veterans who are assessed to be at high risk for suicide warrant a High Risk for Suicide Patient Record Flag (HRS-PRF). This decision is driven by clinical decision-making and will conform to accepted standards of suicide risk assessment including the proper use of a National PRF. This policy establishes guidelines for the identification of Veterans who are at a high risk for suicide, and communicating such information to staff in order to enhance safety for those at risk.

II. POLICY: It is the policy of this facility to determine which Veterans may be at high risk for suicide and to insure that those Veteran’s electronic records are flagged appropriately to enhance the safety and appropriate clinical care of the identified Veteran. High Risk for Suicide flags will not be implemented for any purpose other than to enhance safety for Veterans and staff, and to facilitate delivery of safe and appropriate medical and mental health care.

III. DEFINITIONS:

A. Category I National PRFs include Veterans who are at high risk for suicide. The use of Category I PRFs should also be strictly limited to information that is essential for the delivery of safe and appropriate medical and mental health care. A progress note in Computerized Patient Record System (CPRS) must also accompany all Category I PRFs.

B. High Risk for Suicide: Veterans may be determined to be at high risk for a variety of reasons and this is always a clinical judgment made after an evaluation of risk factors (e.g. history of past suicide attempts or recent discharge from an inpatient behavioral health unit), protective factors, and the presence or absence of warning signs as listed within the VA’s Suicide Risk Identification Strategy. The following list, although not exclusive, contains indicators that a Veteran may be considered at high risk for suicide:

1. A current verified report or witnessed episode of self-directed violence;

2. Identification of current suicidal ideation that requires an immediate change in treatment plan, such as hospitalization;

3. Presence of any of the following warning signs:

a. Thinking about hurting or killing oneself;

b. Looking for ways to kill oneself ;

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c. Talking or about death, dying, or suicide;

d. Self-destructive behaviors such as drug abuse, weapons, etc.

C. A Suicide Behavior and Overdose Report (SBOR) is completed for:

1. Completed suicide;

2. Suicide attempt;

3. Veterans with suicidal ideation with intent and plan that requires an immediate modification of treatment. This note template is completed in CPRS and details the event, level of lethality, and Veteran’s intent which assists the clinician in making an assessment of risk. This report is also used to provide required information for the National Patient Safety reporting requirements on suicides and suicide attempts.

IV. PROCEDURES: When a Veteran has been identified, by assessment and evaluation, as being at high risk for suicide, the Veteran’s medical record is flagged in the following manner:

A. The SPC is alerted that a Veteran has been deemed high risk for suicide by being added to a CPRS note as an additional signer, or other appropriate method;

B. The clinical staff that has initial contact with, and knowledge of the event, documents the event by completing the SBOR.

C. Utilizing the definition of “high risk” provided in VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide dated July 18, 2008, the SPC consults with the Behavioral Health (BH) and Primary Care (PC) teams to determine if a PRF is appropriate. The decision to establish a flag is based on, but not limited to, past history of self-directed violence, risk factors, and other relevant factors.

When warranted, a descriptive flag is entered in Veterans Health Information Systems & Technology Architecture (VISTA). Flags are compliant with the VHA Directive 2008- 036, referenced above.

D. A CPRS note titled “Patient Record Flag Category I High Risk for Suicide” is entered and connected to the patient record flag. The information in this note will include the date when the Veteran was deemed at high risk for suicide and the reason for the high risk designation. Additional signers to this note will include, at a minimum, the PC Provider (PCP) and BH providers.

E. The SPC in conjunction with the SRRT and the Veteran’s treatment team will review the flag approximately 90 days after initial activation or continuation of the flag and make a determination regarding inactivation or continuation of the High Risk PRF, accompanied by an appropriate progress note indicating the rationale behind this decision. This progress note is alerted for PC and BH providers’ co-signature. A

3 Medical Center Memorandum PC-110 reminder for upcoming review is generated 30 days prior to the 90-day anniversary date of each PRF.

V. RESPONSIBILITIES:

A. The Director, or designee, is responsible for:

1. Ensuring that the Category I HRS-PRF is originated and accessible through

CPRS;

2. Establishing a process for requesting, assigning, reviewing, and evaluating Category I HRS-PRFs and coordinating this with the existing processes for managing the PRF Program;

3. Ensuring training by the SPC of appropriate staff in determining when a Category I HRS-PRF is to be entered, how PRFs are entered, and how PRFs and related documents are reviewed and maintained;

4. Evaluating the facility process to ensure the category I HRS-PRF is assigned appropriately;

5. Ensuring that each Category I HRS-PRF in a Veteran’s record is accompanied by the appropriate CPRS note;

6. Ensuring the Category I PRF is used as a local alert for Veterans at high risk of suicide. This use of the Category I flag enables staff to be aware of a Veteran in need of close follow-up, including outreach efforts if the Veteran misses, cancels, or reschedules an appointment;

7. Ensuring when a HRS-PRF is placed on a Veteran’s chart, it is reevaluated at least every 90 days to ensure that the PRF is promptly removed when the high risk status has resolved. This is based on clinical judgment of the conditions and behaviors involved;

8. Ensuring that there is always an “acting” SPC when the SPC is absent.

B. The Chief of Staff (COS) is responsible for: Instituting procedures to ensure that the utilization of a Category I HRS-PRF and the associated processes for recommending such a PRF are ethical, clinically appropriate, supported by adequate resources, and used in accordance with VHA Directive 2008-036, July 18, 2008.

C. SPC is responsible for:

1. Conducting the SRRT, which is comprised of:

a. SPC (Chairman);

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b. Clinical representatives from BH and other appropriate clinical services;

c. A CBH Psychologist.

2. Managing the process of using Category I PRFs to identify Veterans at high risk for suicide;

3. Overall responsibility for management of all Category I HRS-PRFs and limiting their use to Veterans who meet criteria for activation of the High Risk for Suicide

PRF;

4. Assessing the risk for suicide in individual Veterans in conjunction with their treatment team and Mental Health Treatment Coordinators (MHTC);

5. Identifying training needs relating to the prevention and management of suicide;

6. Ensuring that scheduled Veterans identified as being at high risk for suicide receive follow-up for any missed appointments in conjunction with clinical treatment team, and that this follow-up is documented in the electronic medical record (Attachment A);

7. Working with clinicians, who refer potential high risk patients for flagging, to determine the advisability of the flag;

8. Responsible for the management of Veterans who currently have a high risk flag and establishing a system of reviewing the high risk flags with the SRRT at no less than every 90 days; and

9. Documenting, when appropriate, the nature of the follow up and plans for continuing treatment in the electronic medical record.

VI. REFERENCES:

Department of Veterans Affairs, Office of the Inspector General. Implementing VHA Mental Health Initiatives for Suicide Prevention, dated May 10, 2007.

Mental Health Initiatives Memorandum, Deputy Under Secretary for Health Operations and Management, dated June 1, 2007.

VHA Memorandum from the DUSHOM, “Eliminating Veteran Suicide:

Implemention Update on Suicide Risk Screening and Evaluation (Risk ID Strategy) and the Safety Planning for Emergency Department (SPED) Initiatives, dated, October 17, VHA Directive 2008-036, Use of the Patient Record Flag to Identify Patients at High Risk for Suicide; July 18, 2008.

VII. RESCISSION: Medical Center Memorandum PC-110 dated January 9, 2009.

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SHARON COYLE, MSN, RN, MBA

Interim Director

Attachment: A

(Automatic Review Date: November 25, 2022)

Butler VA Health Care System Medical Center Memorandum PC-110 Butler, PA November 25, 2019

ATTACHMENT A

DOCUMENTATION IN THE ELECTRONIC MEDICAL RECORD

Attention – This Veteran is considered to be at high risk for self-directed violence.

Nature of the self-directed violence – Please see CPRS notes for details.

Clerical Staff:

Please verify Veteran’s telephone number, address, and alternate contact information at each clinic visit. Notify provider and suicide prevention coordinator, by 3pm today, if Veteran No-Shows, cancels, or reschedules an appointment.

Providers:

If the Veteran No-Shows, cancels or reschedules an appointment, the provider is to:

1) Telephone Veteran (today) to assess safety and any other needs.

2) Conduct and review depression/suicidal assessments, if there are any concerns and document.

3) Provide Veteran with Veterans Crisis Line number (1-800-273-8255, Press #1), 911 and any other appropriate contact/crisis telephone numbers.

4) If the Veteran is in acute need of emergency intervention, local authorities may need to be contacted for a home “health and welfare” check. Keep the Veteran on the phone and have another staff member call 911 with pertinent information.

5) If you need assistance with management of this Veteran contact the facility Suicide Prevention Coordinator at ext. 6096 or cell number 724-496-2315.

ALL OUTREACH EFFORTS MUST BE DOCUMENTED.