Risk Assessment and Safety Plan (Older Adult)

Encounter Date/Time: [Encounter Date/Time]

Setting: [ED / inpatient / clinic / long-term care / home visit]

Reason for Assessment: [Reason for Assessment]

Assessment Context

Sources: [Information sources and collateral contacts] (List all sources used and identify the primary informant.)

Reliability and Limitations: [Factors affecting reliability and communication] (Include cognitive impairment, delirium, intoxication/withdrawal, aphasia, sensory deficits, guardedness, language barrier. Note communication supports used and whether caregiver presence limited privacy.)

Cognitive and Functional Status: [Baseline cognition and recent changes] [Relevant diagnoses] [Cognitive screen tool and score if performed] [Capacity to participate in safety planning] [Functional abilities affecting plan feasibility] [Living situation and supervision level] [Who controls medication and firearm storage] (Assess ability to understand and execute plan steps independently.)

Plan Adaptation for Impairment: [Explicit statement on whether cognitive/functional impairment affects safety plan feasibility and how the plan accommodates this] (Include only if impairment materially affects the plan.)

Presenting Concern

[Narrative of precipitating event(s), proximate trigger/stressor, and patient's subjective experience] (Use direct quotes for high-salience statements such as suicidal intent, threats, command hallucinations, or burdensomeness. Include relevant older adult modifiers: grief/bereavement, loneliness, loss of independence, new diagnosis, pain, insomnia, caregiving stress, financial concerns, or transitions in living situation.)

Suicide and Self-Harm Risk Assessment

Screening Result: [Tool name/version, date, and key item results] (Omit if no validated tool was administered; instead document assessment approach used.)

Current Suicidal Ideation:

• [Passive death wish vs. active suicidal ideation]
• [Frequency, intensity, duration, controllability, triggers]
• [Intent: none / ambivalent / present] [Reasons for living or deterrents]

Plan, Means, and Preparatory Behavior:

• [Plan presence: none / vague / specific] [Contemplated method] [Timeframe: immediate / vague]
• [Access to means: firearms, medications, sharps, toxins, ligature points, vehicle, heights] (Must be explicitly assessed or documented as unknown.)
• [Preparatory acts] (Include only if present: gathering pills, writing notes, giving away possessions, researching methods.)

Past Suicidal Behavior:

• [Prior attempts: number, approximate dates, methods, medical lethality, stated intent, rescue circumstances]
• [Aborted or interrupted attempts]
• [Non-suicidal self-injury] (Label distinctly if present.)

Acute Risk Factors:

• [Psychiatric factors: depression, anxiety, psychosis, trauma, substance use]
• [Medical factors: chronic pain, terminal illness, sleep disorder, neurological disease, medication side effects]
• [Social factors: isolation, recent losses, caregiver burden, interpersonal conflict, perceived burdensomeness]
• [Neurocognitive factors: dementia, delirium, impaired judgment]
• [Treatment engagement and barriers to care]

Violence Risk Assessment

[Homicidal or violent ideation: none / passive / active] (If none, one concise sentence suffices and remainder of section may be omitted.)

• [Target specificity: none / general / specific person]
• [Plan and intent]
• [Access to weapons and proximity to target]
• [Recent threats or aggressive behavior]
• [Risk amplifiers: intoxication, delirium, paranoia, command hallucinations, agitation, history of violence, firearm access]
• [Protective factors: supervision, remorse, willingness to accept help, separation from target, weapon removal]

[Credible threat narrative: who is threatened, nature/credibility, and immediacy] (Include only if credible threat exists.)

Protective Factors

• [Connectedness: family, friends, faith community, pets, facility ties]
• [Internal factors: coping skills, future goals, reasons for living]
• [Care engagement: willingness to engage treatment, therapeutic alliance, follow-up capacity]
• [Environmental factors: restricted access to means, supervised medication administration, supportive housing]

[Narrative synthesis with limitations] (Document strengths alongside constraints. Do not use protective factors alone to justify low risk without addressing acute factors.)

Risk Formulation

Suicide Risk Level: [low / moderate / high / imminent]

Violence Risk Level: [low / moderate / high / imminent] (Omit if no violence concern.)

Acute versus Chronic: [above baseline / at baseline / below baseline]

Rationale:

• [Key acute factors: plan/intent/access, recent behavior, intoxication, delirium]
• [Key protective factors with limitations]
• [Data limitations affecting confidence]
• [Additional salient considerations]

(Do not assign low risk solely based on denial of ideation; integrate access, history, reliability, and context.)

Interventions This Encounter

• [Immediate safety actions: observation level, removal of dangerous objects, sitter, security involvement, emergency hold]
• [Clinical actions: medication changes relevant to safety, deprescribing high-risk sedatives, delirium workup, pain management]
• [Care coordination: contacted caregiver/facility, contacted outpatient clinician, arranged transport, warm handoff to behavioral health or crisis team]

Means Safety Plan

Current storage/access assessed: [Items reviewed: firearms, ammunition, medications, sharps, toxins]

Counseling provided: [yes / no] [Topics covered]

Agreed plan: [Specific changes to reduce access, responsible party, storage location, timeframe, and verification method]

If means restriction refused: [Refusal and stated reasons] [Alternative mitigation steps] (Include only if patient declined means restriction.)

Safety Plan

Warning Signs: [Early indicators that a crisis may be developing]

Internal Coping Strategies: [Strategies the patient can use independently] (Prefer patient-identified strategies.)

Social Contacts for Distraction: [Names and contact methods] (Note accessibility given mobility/transportation.)

People to Contact for Help: [Names, roles, and contact methods] (For hearing impairment, specify preferred mode.)

Professional and Crisis Resources: [Clinic contact and after-hours coverage] [988 Suicide and Crisis Lifeline] [Local crisis line or mobile crisis] [ED instructions]

Environment Safety: [Brief restatement of means restriction plan]

Reasons for Living: [Patient-identified anchors] (Optional but recommended.)

Feasibility Adaptations: [Independent use vs. caregiver/facility support, simplifications, accessibility accommodations] (Include if cognitive or functional impairment affects plan execution.)

Plan Location: [Where the safety plan will be kept]

Disposition and Follow-Up

Disposition: [outpatient / higher level of care / ED transfer / inpatient admission] [Brief rationale tied to risk formulation]

Follow-Up Appointment: [Date, time, location or telehealth link] (If not scheduled, document barrier and interim plan.)

Between-Visit Monitoring: [Caregiver check-in plan, facility observation level, clinician outreach, medication dispensing controls]

Escalation Thresholds: [Clear instructions for when to contact crisis services vs. ED/911]

Notifications

[Collateral contact consent status and who was contacted] [Contacts without consent due to safety concerns with clinical justification] [Duty-to-protect notifications: who and when] [Adult protective services referral if applicable] (Omit entire section if no notifications were required.)

Patient and Caregiver Understanding

Patient understanding and agreement: [Teach-back summary and level of agreement] (Document disagreements and how addressed.)

Caregiver/facility understanding and agreement: [Understanding of responsibilities and agreement to implement] (Include only if caregiver/facility responsible for plan elements.)