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Institutional Handbook of Operating Procedures Policy 09 ...

Institutional Handbook of Operating Procedures Policy Section: Clinical policies Responsible Vice President: Executive Vice President UTMB Health System Subject: General Responsible Entity: Quality Management I. Title Suicide Risk Screening and Suicide Precautions for Patients II. Policy The University of Texas Medical Branch (UTMB) Health System is committed to providing a safe environment for patients, students, visitors, and employees. Identification of individuals at risk for suicide while under our care and following discharge is an important step in protecting those individuals at risk. Determining Need for and Conducting Suicide Risk Screening: Clinical staff who perform intake screening on patients 12 years old or older, within the UTMB Health System, will document whether or not a patient is being evaluated or treated for a behavioral health condition as their primary reason for care.

1. Implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals served at risk for suicide will be monitored for compliance. 2. Actions will be completed as needed to improve noncompliance with …

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