C-SSRS SCREEN

Screen date and time: [Date, time]
Patient: [Name or record number, age]
Setting: [Emergency department, inpatient unit, clinic, telehealth, or other]
Asked by: [Name, role]
Version used: [Screener recent, screener since last contact, full scale lifetime and recent, or since last visit]
Language: [Language used; interpreter name or ID if one helped]
Why screened: [Universal screen, positive depression item, concern raised by patient or family, or repeat check]

ANSWERS
Timeframe: [Past month for thoughts, lifetime and past 3 months for behavior; or since last contact]
Questions asked: [Which questions were asked, following the official skip pattern]
Answered yes: [Question numbers answered yes, in the patient's words where useful]
Behavior: [None, lifetime only, or within the past 3 months; what happened and when]
Highest yes: [0 to 6]

RISK LEVEL
Screen result: [None, low, moderate, or high]
Basis: [The answer that set the level, and its timing]
Clinician review: [Who reviewed the screen, and whether a full risk assessment followed]

ACTIONS TAKEN
Safety plan: [Made, reviewed, or not indicated]
Means safety: [Firearms, stored medicines, and other means discussed; who is securing them]
Referral: [Behavioral health referral or consult, with date]
Emergency evaluation: [Not needed, or arranged: where, how the patient got there, observation level]
Crisis contacts: [988 by call or text, and local crisis services given]

WHO WAS TOLD
Care team: [Nurse, physician, or behavioral health clinician informed, with the time]
Family or support person: [Who, with the patient's agreement, or the reason it was done without it]
Next screen: [When the next C-SSRS is due, and which version]

Signed: [Name, credentials]