If patient answers “No” to all questions 1 through 4, screening is complete (not necessary to ask question #5). No intervention is necessary (*Note: Clinical judgment can always override a negative screen).
If patient answers “Yes” to any of questions 1 through 4, or refuses to answer, they are considered apositive screen. Ask question #5 to assess acuity:
Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. If a patient (or parent/guardian) refuses the brief assessment, this should be treated as an “against medical advice” (AMA) discharge.
Alert physician or clinician responsible for patient’s care.
