Point of Care

Violent Behaviour Assessment Considerations

For each of the four categories below, note the number indicating the level observed, and record on the Assessment Record 4. Ensure appropriate care
planning 5 and risk reduction interventions (see next page) are in place, prioritizing greatest risk.
Category: Observed Behaviours Any observation at 4-5 merits further observation and intervention

Behavioural Emergency P Personal Space Invaded
5 A Activity level increasing
V Verbal Violence
Interferes with medical equipment that could Physically strikes out/assaults person (e.g. biting,
result in harm to patient. punching, kicking) with or without a weapon which
Weapons displayed; clenched fists. would expected to cause serious injury or death.
Throwing items/destruction of property. Risk or elopement by certified patient.

Escalating Emotional Crisis/Active Resistance Extremely withdrawn/internally focused Irritable (excitable, annoyance, impatience, anger)
Emotionally distraught, resistive to care Verbally & physically resistant
4 Slamming doors, clenched fist Actively uncooperative
Intrusive of distracting to others No longer able to follow a simple command
Impulsive/sudden behaviour change Does not respond to limit setting
Emotional Crisis Coping skills/abilities challenged S Staring (prolonged or avoid eye contact)
T Tone of voice (rude/sarcastic)
3 A Anxiety (jittery, crying, flushed face)
M Mumbling (muttering, slurred speech)
P Pacing (walking around confined area)
2 Does not want to cooperate, but can control him/herself when asked Passive Resistance
1 Behaves appropriately - cooperative (follows directions and/or instructions) Compliant/Cooperative

Category: Cognitive/Emotional Status Any observation at 4-5 merits further observation and intervention

Displays or self/significant other Command hallucinations of violent nature Drug/alcohol intoxication

5 reports one or more of the Feels constantly provoked Unable to calm self through discussion
following: No control over reactions Feelings of extreme anger or despair and/or thoughts of anger/inflicting harm
Complete lack of insight History of violence: in the past year OR more than one violent incident
Impaired insight of physical limitations or consequences of action and/or Easily provoked History of violence
describes angry thoughts but able to calm self through discussion of same in Paranoia Causative factors are controlled (i.e., med.
4 Poor insight changes, acute psychotic symptoms, etc.)
rational manner.
Incoherent thoughts Poor control over reactions

3 Disoriented to person, time or place and/or describes irritable thoughts Insight intact
2 Inconsistently oriented to person, time or place
1 Oriented to person, time or place and/or no indication of violent thoughts
Category: Communication Any observation at 4-5 merits further observation and intervention

Unable to communicate appropriately due to extreme Swearing, loud/yelling directed towards staff Rapid speech
5 verbal conduct Making threats of harm/self-harm Clients delusional content directed specifically at
staff or clients
Unwilling to communicate appropriately Aggressive questioning Refusing treatment
Does not follow direction Insulting
4 Challenging, demanding Clients delusional content directed specifically at
staff or clients
Aphasia Cognitive impairment (i.e. head injury, intoxication,
3 Unable to make self understood Language barrier e.g. foreign dialect, disordered thought formation, and/or
language or strong accent developmentally delayed)
Dysphasia Cognitive impairment (i.e. head injury, intoxication,
2 Partially able to make self understood Language barrier e.g. foreign dialect, disordered thought formation, and/or
language or strong accent developmentally delayed)

1 Understands, makes self understood, appropriately and respectfully

Category: Ability to Inflict Physical Harm Any observation at 4-5 merits further observation and intervention

5 Significant strength and mobility to inflict harm Punch Kick

Slap Grab
4 Strength and mobility to inflict harm Bite, Scratch Pull hair
3 Strength, but restricted mobility to inflict harm Confined to wheelchair or bed
Vision impairment Weak limbs
2 Lack of strength, and limited mobility, to inflict harm due to clinical conditions Poor balance
1 Lack of strength and mobility to inflict harm

4
Refer to Violence Risk Assessment & Activation Form
5
Refer to Violence Aggression Behavioural Care Plan
This tool should be used in conjunction with Transporting Clients Weapons & Prohibited Items in the Workplace
appropriate VIHA Policies including: Working Alone or in Isolation Searching Patients Belongings, Room & Person for Weapons & Prohibited Items
Violence Risk Communication Restraints and Alternative Ways of Managing Unsafe Patient Behaviour
violent-behaviour-assessment-considerations- Revised: August 2013 Page 2 of 3
tool.doc Adapted from Northern Health & BC PVPC
 Point of Care
Violent Behaviour Assessment Considerations

Interventions to Consider
Note: This is not an exhaustive or prioritized list and is meant to guide staff actions. Assessing and responding to behaviour is a dynamic and
constant process, due in part to the influence of sudden and changing circumstances.
Score Risk Level Identified Risk & Interventions to Consider Based on Observations
15-20 High Withdraw from situation if behaviour is threatening to personal safety return when safe to re-engage.
Monitor for compliance with simple requests e.g. please sit down.
If non-compliant with requests:
o Implement a team approach to ensure immediate presence of other staff.
o If any other person is associated with triggering the behaviour, respectfully request they leave the environment (family
member, staff member, visitor) and seek alternative staff to assist if required.
o Call Code White, protection services (where available) and/or police and use restraints if the patient is a danger to
themselves/others.
Relocate patient to a quiet environment.
Communicate the nature and level of risk, together with risk mitigating actions, to all workers interacting with the
patient, and across the care continuum, particularly prior to patient transfer e.g. ensure safety board updated with
relevant need to know information about safe care delivery.
Address underlying risk factors/clinical conditions and stressors and ensure that care needs are met.
o See: Alternatives to Restraints: Managing Unsafe Patient Behaviours
Reassess against the assessment score at a minimum of once per shift and implement behaviour tracking tool
Seek additional history and assess for relevance to current situation and consider initiating purple dot/electronic alert
as per Violence Risk Communication policy.
Ensure appropriate narrative notes on nature of the risk are placed on the patients health record, and that care
planning and risk reducing interventions are in place.
9-14 Moderate Withdraw from situation if behaviour is threatening to personal safety return when safe to re-engage.
Monitor for compliance with simple requests e.g. please sit down.
Consider use of a team approach involving additional staff in care provision.
Relocate patient to a quiet environment.
Communicate the nature and level of risk, together with risk mitigating actions, to all workers interacting with the
patient, and across the care continuum, particularly prior to patient transfer e.g. ensure safety board updated with
relevant need to know information about safe care delivery.
Ask the patient how you can assist.
Determine if a family member or significant other can assist.
Address underlying risk factors/clinical conditions and stressors and ensure that care needs are met.
o See: Alternatives to Restraints: Managing Unsafe Patient Behaviours
Reassess against the assessment score at a minimum of once every 48 hours
Seek additional history and assess for relevance to current situation and consider initiating purple dot/electronic alert
as per Violence Risk Communication policy.
Ensure appropriate narrative notes on nature of the risk are placed on the patients health record, and that care
planning and risk reducing interventions are in place.
4-8 Low Utilize Universal Safety Precautions and Monitor for sudden changes in baseline behaviour.
Reassess patient and situation if there is a sudden change in cognitive, emotional, behavioural or ability to inflict
harm or communicate.
6
ALL ALL Irrespective of risk potential, implement Universal Precautions for Violence Prevention
o e.g. attentive and empathetic verbal/non-verbal communication strategies
Get to know the patient
Reassess the patient and situation if there is a cognitive or behavioural change
Refer to program specific and/or disease specific strategies where available
Assess and treat underlying cause(s) and unmet care needs

6
See Universal Precautions for Safety and Violence Prevention Tool
This tool should be used in conjunction with Transporting Clients Weapons & Prohibited Items in the Workplace
appropriate VIHA Policies including: Working Alone or in Isolation Searching Patients Belongings, Room & Person for Weapons & Prohibited Items
Violence Risk Communication Restraints and Alternative Ways of Managing Unsafe Patient Behaviour
violent-behaviour-assessment-considerations- Revised: August 2013 Page 3 of 3
tool.doc Adapted from Northern Health & BC PVPC