D21 - VA Suicide Prevention Safety Plan and SBOR.pdf

FOR VA INTERNAL USE ONLY 08/17/2022

v2

Department of Veterans Affairs (VA) Suicide Prevention Safety Plan and Suicide Behavior and Overdose Report (SBOR) Templates

Staff Specific Guidance

A Suicide Prevention Safety Plan is a brief clinical intervention, collaboratively developed between a patient and a provider, for use during or before a suicidal crisis. VHA staff members can develop a safety plan with a patient if:

1. There is a “Yes” next to the staff member’s credentials in the table below; AND

2. The local facility Chief of Staff concurs with this determination; AND

3. Safety planning is within facility scope of practice and/or competency.

Suicide Behavior and Overdose Reports (SBOR) collect information on suicidal behaviors and non-suicidal overdoses that result in an adverse event. VHA staff members can complete an SBOR if:

1. There is a “Yes” next to the staff member’s credentials in the table below; AND

2. Completion of the SBOR is within facility scope of practice and/or competency.

SBOR SP Safety Plan MD/DO1 Yes Yes Licensed Psychologist (PhD/PsyD)2 Yes Yes Clinical Pharmacist Practitioner Yes Yes LCSW/LMSW/LISW3 Yes Yes LMFT4 Yes Yes LPMHC5 Yes Yes Addiction Therapist Yes Yes LPN6 No No RN7 Yes Yes APRN: NP/CNS8 Yes Yes PA9 Yes Yes Peer Support Specialist No No UAP10 No No Psychological Technician, Social Work Assistant

No No

Vocational Rehabilitation Specialist No No Rehabilitation Counselor Yes Yes

1Medical Doctor/Doctor of Osteopathic Medicine; 2Doctor of Philosophy/Doctor of Psychology; 3Licensed Clinical Social Worker/Licensed Master of Social Work/Licensed Independent Social Worker; 4Licensed Marriage and Family Therapist; 5Licensed Professional Mental Health Counselor; 6Licensed Practical Nurse; 7Registered Nurse;

8Advanced Practice Registered Nurse: Nurse Practitioner/Clinical Nurse Specialist; 9Physician’s Assistant;

10Unlicensed Assistive Personnel, including Health Tech, Medical Assistant, and Nursing Assistant.

Note: A trainee in ANY of these categories may complete each step marked with a “Yes” with an appropriate co-signer.

If a particular discipline is not identified in the table above, the discipline may not complete the Safety Plan or the

SBOR.