Mandated Report or Duty to Protect Documentation Note

Date/Time of Note: [Date and time of documentation entry] (Use local date and time; include time zone if relevant.)

Date/Time of Triggering Event: [Exact time or best estimate] (If uncertain, document best estimate and basis for estimate.)

Author: [Name, credentials, role]

Service/Location: [Clinic/service name and physical or telehealth setting]

Patient: [Patient name and identifiers per local policy]

Encounter ID: [Encounter identifier/reference]

Supervisor/Attending: [Name and role] (Enter "N/A—independent clinician" if not applicable.)

Co-signature Required: [Yes / No]

Triggering Event Summary

Trigger category: [Trigger category] (Select all that apply: mandated report for suspected child abuse/neglect; elder/dependent adult abuse/neglect/exploitation; reportable injury; other legally required report; duty to protect/warn for credible threat to identifiable person; serious imminent threat to self; other imminent safety threat.)

Source of information: [Source(s) of information] (Select all that apply: patient disclosure; third-party disclosure; observed findings; collateral record; law enforcement/agency contact; other.)

Narrative summary: [Objective description of what occurred, who disclosed, and why action is triggered] (2–5 sentences. Include direct quotes for threats and key disclosures in quotation marks. If not verbatim, label as paraphrase. Maintain objective, factual, time-anchored tone.)

Immediate Safety Assessment

(Include this section when any possibility of imminent harm existed at time of event.)

Imminent risk determination: [Yes / No / Uncertain] — [Specific supporting facts]

• Access to means: [Weapons, medications, or other means availability; proximity to target]
• Timeframe stated: [Stated or inferred timeframe, or "none stated"]
• Identifiable target(s): [Name, role, and/or relationship, or "not identified"]
• Protective actions taken: [Actions taken] (Examples: increased observation, security involvement, means restriction, emergency services activation, involuntary hold steps, ED transfer. If no immediate protective action was taken, explicitly state the rationale.)

Reporting Decision Basis

[Brief explanation of how the decision to report or disclose was reached] (For mandated reports: state facts meeting threshold for suspicion, whether report is legally required vs. permissive vs. institutional policy, and applicable jurisdiction if it affects agency selection. For duty to protect/warn: state why the threat met threshold—credibility, seriousness, imminence, identifiable victim, access/ability—and action(s) selected: warn potential victim, notify law enforcement, initiate hospitalization, or combination.)

Confidentiality statement: [Authorization obtained / Authorization attempted / Authorization not indicated] — Information disclosed was limited to what was necessary for the report or safety purpose.

Consultation and Supervision

• [Date, time, method, person consulted (name, role), summary of guidance received, and decision made after consultation]
• [Additional consultations as applicable: clinical supervision, risk management/legal counsel, interdisciplinary team, external consults]

(If no consultation was obtained, state "No consultation obtained" with rationale—e.g., time-critical, followed standing protocol, supervisor unreachable. Use accurate language such as "supervisor notified," "case discussed," or "recommendation received"—do not imply supervisor agreement unless explicitly obtained.)

Reporting/Disclosure Event Log

(Enter each action as a separate, time-stamped entry in chronological order. Example format: "14:22 — Called CPS hotline; spoke with J. Smith, intake worker; phone; report accepted; Reference #12345.")

• [Date/time] — [Action taken]; [Recipient: agency, jurisdiction, person spoken to and title]; [Method: phone / online portal / fax / in person]; [Outcome: connected / no answer / left message / report accepted]; [Reference/case/incident number, if provided]
• [Additional entries as needed]

Categories of information disclosed: [Patient identifiers disclosed; nature of concern/allegation and pertinent facts; direct quotes of threat or key disclosure if applicable; safety concerns including weapons access, means, identifiable victim information; immediate safety steps already taken]

(If a report could not be completed, document barriers, attempts made with timestamps, interim safety measures, and plan to complete including responsible party and timeframe.)

Patient Notification

Patient informed of report/disclosure: [Yes / No / Deferred]

• If Yes: [Date/time notified; what was explained (limits of confidentiality, what was reported, to whom); patient response in their words or observed behavior; questions answered]
• If No: [Specific rationale: risk of harm / contraindicated / patient lacked capacity / safety concern regarding personal representative as suspected perpetrator / other]
• If Deferred: [Planned timing and method of notification; safety conditions required before notification]

Additional consent obtained: [If authorization was obtained to share information beyond legal minimum, specify what was authorized, or "N/A"]

(Do not document that patient "understands" unless understanding was demonstrated; instead document patient's statements or observed behavior.)

Follow-Up Plan

• Immediate disposition: [Remains in clinic / Admitted / ED transfer / Discharged / Left AMA / Other] (If patient left before completion, document last known status and steps taken.)
• Safety interventions provided: [Crisis resources, emergency contacts, lethal means counseling, protective actions, welfare check requests]
• Clinical follow-up: [Next appointment or follow-up interval; referrals to social work, protective services liaison, advocacy services, psychiatry, case management]
• Coordination tasks: [Who will follow up on case/reference number; communicate with agency; update care team]
• Documentation plan: [Addendum to be filed when reference number received and/or written report confirmation obtained]

Signature

[Clinician signature, credentials, date/time]

[Supervisor/Attending co-signature, if required]

(Use addenda—not silent edits—for late-arriving reference numbers, written report confirmations, additional disclosures, or outcomes communicated by agencies.)