SC Daily Assessment/Discharge
Precision Psychiatric Services
Name
DOB
Evaluation Date/Time
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Evaluation
Daily Follow Up
Discharge from SC
Reason for Watch
SI/Threat
Plan
Act
Other
Date placed on watch
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Days on Watch
Type of Watch and Frequency
Constant
Staggered 15 minutes
Other, indicate watch frequency
Interventions during session
Since last visit has patient engaged in any self harm?
Yes
No
Unknown
Behaviors of Concern
Appearance:
Appropriate
Meticulous
Unclean
Disheveled
Other
Speech:
Appropriate
Expressive
Loud
Slowed
Pressured
Slurred
Other
Mood:
Appropriate
Depressed
Euphoric
Anxious
Angry
Irritable
Other
Affect:
Appropriate
Tearful
Blunted
Flat
Labile
Hostile
Other
Thought Process:
Coherent
Circumstantial
Tangential
Loose Associations
Poverty of Thought
Flight of Ideas
Other
Thought Content:
Appropriate
Auditory Halucinations
Visual Hallucinations
Obsessive
Delusional
Suicidal Ideations
Homicidal Ideations
Other
Orientation:
Person
Place
Time
Situation
Intelligence:
above average
average
below average
well below average
Memory:
Intact
Immediate impaired
Recent impaired
Remote impaired
Insight:
Good
Fair
Poor
Judgement:
Good
Fair
Poor
Behavior:
Appropriate
Belligerent
Agitated
Impulsive
Withdrawn
Other
Current Status:
Medication Adherent?
Yes
No
N/A
Suicidal Ideations Noted?
Yes
No
Refused to answer
Homicidal Ideations Noted?
Yes
No
Refused to answer
Estimated current suicide/self harm risk:
Low
Intermediate
High
Identify Reason Patient to Remain on Watch (including recent stressors, active ideation and/or plan)
Identify Rationale for Downgrading Watch
Identify Rationale for Discontinuing Watch
Plan
Discharge from watch, follow up in accordance with policy or sooner as clinically indicated.
Continue current suicide watch and follow up daily
Change level of watch to:
Clothing Allowed (only allowed if checked):
Safety blanket
Safety smock
Paper gown
Regular uniform
Other
Food Allowed (only allowed if checked):
Finger food
Regular Tray
Other
Other items allowed (only allowed if checked):
Book
Glasses
Hygiene products
Other
Placement
Appropriate for General Population
Other
Refer to
Medical
Psychiatry
Special Needs
Other
Psychiatrist within ( ) days?
Patient will need follow up again with Clinician on:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Qualified Provider Name
Qualified Mental Health Professional (Signature)
Date/Time
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: