Beruflich Dokumente
Kultur Dokumente
RA
Confidential
This form is to be completed following the assessment and/or review of risk, in accordance with local Clinical Risk Management Standards.
Written details of current and past risks/behaviour should be provided on p.2/3. This form must be photocopied onto gold coloured paper
Assessment summary
Surname:
Risk history
First name:
Alias::
Gender:
No
NHS number:
Title:
Base:
Yes
Not known
Name:
CPA (circle)
SUI
No
Date of birth:
Tel:
Near miss
Yes
No
N/A
Probation services
Social Services
Police
Voluntary sector
Other (specify)
None
On leave
Risk of suicide
Informal
s117
Risk of self-harm
Detained
Guardianship
Assessment details
Assessed by:
Designation:
Date of assessment:
Location of assessment:
Yes
No
Yes
No
Yes
No
Initial
Review
Discharge
Follow-up
Yes
Signed:
No
Date:
History
Current
No
No
History
Current
No
No
Notes
Treatment-related indicators
History
No
Current
No
Discontinuation of medication
Failure to attend appointments
Unplanned disengagement from services
Compulsory admission
Supervised discharge
Restriction order
Conditional discharge
Forensic history
History
No
Current
No
History
No
Current
No
2000-3 FACE Recording & Measurement Systems DMHST Records Management Approved Clinical Document Nov 2010
page 2 of 4
None
Self
Partner/spouse
Staff member
General public
Child
Parent
Group (specify)
Other (specify)
Have actions been taken in the past to reduce risk? (Detail, including effectiveness)
Yes
No
Unclear
No
Unclear
Service users view of risk (Give details, including persons view of what is needed to reduce risk)
Is the service user aware of possible risks?
Yes
Protective factors
2000-3 FACE Recording & Measurement Systems DMHST Records Management Approved Clinical Document Nov 2010
page 3 of 4
Agreed by:
Date applied:
Review date:
Steps to be taken if service user fails to attend or meet other commitments (tick, detail below)
None
Contact GP
Telephone
Visit home
Other (specify)
Information sources available / accessed in completing risk profile (Tick all sources used)
Service user
Copies sent to: (tick)
Case notes
Date
Carer/relative
Other (specify)
File
GP
Care co-ordinator
Social services
User
Other
Signed:
Designation:
Date:
Date:
2000-3 FACE Recording & Measurement Systems DMHST Records Management Approved Clinical Document Nov 2010
Date
page 4 of 4