Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Violence Risk to Self

Release Notes:
Data Element
Version 2020B

Name:Violence Risk to Self
Collected For: HBIPS-1
Definition:Documentation in the medical record that an admission screening for violence risk to self over the past six months was performed within the first three days of admission. Violence Risk to Self includes: ideation, plans/preparation and/or intent to act if ideation present, past suicidal behavior and risk/protective factors within the 6 months prior to admission.
Question:Is there documentation in the medical record that the patient was screened for violence risk to self over the past six months within the first three days of admission?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Documentation in the medical record includes a screening for violence risk to self over the past six months was performed within the first three days of admission.

N    (No)   Documentation in the medical record does not include a screening for risk to self over the past six months OR the screening was not performed within the first three days of admission OR unable to determine from medical record documentation.

X    (Unable to complete admission screening)   Documentation in the medical record that a screening for risk of violence to self over the past six months can not be completed due to the patient's inability or unwillingness to answer assessment questions within the first three days of admission OR patient has a previous admission to the psychiatric unit during a single hospitalization.

Notes for Abstraction:
  • A screening for risk of violence to self and others must be completed by a qualified psychiatric practitioner e.g., psychiatrist, registered nurse (RN), physician's assistant (PA) or Master of Social Work (MSW) within the first three days of admission. Titles of qualified psychiatric practitioners vary from state to state.
  • The intent of this data element is to screen the patient for being a violence risk to self within the 6 months prior to admission. Documentation of violence risk must at a minimum state over the past 6 months. Documentation of a past history of violence risk should differentiate the risk being either within the past 6 months or prior to the 6 month time frame.
  • Documentation of "no history" cannot be used, unless it is associated with a time frame. For example:
    • “No history of violence risk to self within the past 6 months.”
    • Or
    • “History of violence risk to self over a year ago.”

  • If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, select the first admission to the psychiatric unit.
  • The admission screening must have occurred within the first three days of admission for psychiatric care. The day after admission is defined as the first day. An admission screen performed in an ambulatory setting, i.e. emergency department, crisis center which results in an admission to an inpatient psychiatric care setting can be used if the screen becomes a permanent part of the medical record.
  • Some examples of violence to self include but are not limited to: past suicide attempts by the patient, intentional cutting, burning, bruising or damaging of self by the patient, inappropriate substance use, suicidal thoughts in the past six months by the patient, specific suicidal plan in the past six months by the patient and past suicide attempts by anyone in patient's family.

  • If there is documentation that the patient is not a reliable historian, a relative or guardian if available, may answer the screening questions on behalf of the patient.
Suggested Data Sources:
  • Biopsychosocial assessment
  • Emergency department record
  • Functional skills assessment
  • History and physical
  • Individual plan of service
  • Initial assessment form
  • Nursing notes
  • Physician progress notes
  • Psychiatrist assessment/admission form
  • Referral packet
  • School report
  • Social worker assessment
Additional Notes:

Guidelines for Abstraction:
Inclusion Exclusion
Examples of risk factors may include but are not limited to:

  • Family history of suicide
  • Previous suicide attempt(s)
  • History of alcohol and substance abuse
  • History of mental disorders, particularly clinical depression
  • Feelings of hopelessness
  • Impulsive and/or aggressive tendencies
  • Cultural and religious beliefs, such as the belief that suicide is a noble resolution of a personal dilemma
  • Local clusters of suicide
  • Lack of social support and sense of isolation
  • Loss (relational, social, work, or financial)
  • Physical illness
  • Easy access to lethal means, e.g., weapons, etc.
  • History of trauma or abuse
  • Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts
  • Barriers to accessing mental health treatment
  • Exposure to others who have died by suicide (in real life or via the media and Internet)

Examples of protective factors may include but are not limited to:

  • Receiving clinical care for mental, physical and substance use disorders
  • Access to a variety of clinical interventions and support for help seeking
  • Restricted access to highly lethal means of suicide, e.g., weapons, etc.
  • Interpersonal relationships and supports, i.e., family, friends, peers, community
  • Support through ongoing medical and mental health care relationships
  • Skills in problem solving, conflict resolution and nonviolent handling of disputes
  • Cultural and religious beliefs that discourage suicide and support self-preservation

  • None

Violence Risk to Self
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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