SOP 508.29-att-3: Suicide Precautions Rounds

SOP 508.29
Attachment 3

7/1/20

|Suicide Precautions (SP)
Rounds
(to be completed by the
psychiatrist/psychologist during rounds
on offenders/detainees on SP status)|Facility: ________________________
Offender: _______________________
GDC ID#: ______________________
DOB: __________________________
Race: ___________ Sex: __________
Date: __________________________|
|---|---|
|
D. Offender/Detainees current concerns: __________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Suicide risk indicators: ________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Mental Status:_______________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
|
D. Offender/Detainees current concerns: __________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Suicide risk indicators: ________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Mental Status:_______________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
|
|
A. Current assessment (include risk/protective issues): ______________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
The main psychiatric diagnoses is: [ ] unchanged
[ ] changed to:______________________________________________________
|
A. Current assessment (include risk/protective issues): ______________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
The main psychiatric diagnoses is: [ ] unchanged
[ ] changed to:______________________________________________________
|
|
P. Suicide Precautions Status: [ ] no change
[ ] change to_______________________________________________________
Property restriction/safety precautions: [ ] no change
[ ] change (add or delete) as follows:____________________________________
___________________________________________________________________
___________________________________________________________________
Recommended therapeutic interventions: _________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Recommended Level: ______
|
P. Suicide Precautions Status: [ ] no change
[ ] change to_______________________________________________________
Property restriction/safety precautions: [ ] no change
[ ] change (add or delete) as follows:____________________________________
___________________________________________________________________
___________________________________________________________________
Recommended therapeutic interventions: _________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Recommended Level: ______
|
|
________________________________________ ___________________
Signature (PhD or MD) Date
|
________________________________________ ___________________
Signature (PhD or MD) Date
|

Form no. M69-01-03 Page 1 of 1

Retention Schedule: Completed forms shall be placed in the offender’s mental health file section 1) and a copy in the medical record
(section 5). At the end of the offender’s need for mental health services and/or sentence, the mental health file shall be placed within
the offender’s health record and retained for 10 years.