Trauma-Informed Care Screening Checklist

Inspection template for documenting trauma history screening, trauma-sensitive accommodations, and follow-up actions integrated into behavioral health care.

Screening Workflow and Consent

• Trauma screening is offered in a private, respectful setting
  Confirm the screening occurs where the patient can speak confidentially without interruption or exposure to other patients.
• Patient informed of purpose, limits, and voluntary nature of screening
  Verify staff explain why the screening is being asked, how the information will be used, and any limits to confidentiality.
• Consent or refusal is documented before trauma history questions are asked
  Check that the record shows consent to proceed or a documented refusal/deferral when the patient declines.
• Screening tool used matches approved workflow or SOP
  Confirm the staff member used the approved trauma-informed screening tool, script, or intake workflow for the setting.
• Screening was completed by trained staff
  Verify the person conducting the screening has current training in trauma-informed communication and de-escalation.

Trauma History Documentation

• Trauma history screening result is documented in the record
  Confirm the chart includes whether trauma exposure was disclosed, declined, deferred, or not indicated.
• Relevant trauma triggers or stressors are documented when disclosed
  Check that known triggers, reminders, or stressors that may affect care are recorded in a clinically appropriate manner.
• Patient preferences for communication and touch are documented
  Verify the record includes preferences such as preferred name/pronouns, permission before touch, pacing, or communication style.
• Any immediate safety concerns identified during screening are documented and escalated
  Confirm urgent concerns such as self-harm risk, abuse, or imminent safety issues were documented and escalated per protocol.
• Documentation avoids unnecessary detail that could retraumatize or compromise privacy
  Review whether notes are clinically sufficient without excessive narrative detail that is not needed for care.

Trauma-Sensitive Accommodations

• Accommodations were offered based on patient needs or preferences
  Confirm the patient was offered reasonable trauma-sensitive accommodations such as breaks, support person presence, or modified pacing.
• Environment supports emotional and physical safety
  Verify the setting is calm, private, and arranged to reduce distress where possible.
• Patient was offered choice and control during the encounter
  Check whether the patient could pause, decline questions, choose seating, or otherwise control the pace of the interaction.
• Interpreter, support person, or other communication support was provided when needed
  Confirm accommodations were made for language access, disability access, or support person involvement when indicated.
• Staff used trauma-sensitive language and avoided re-traumatizing prompts
  Observe whether staff used respectful, nonjudgmental language and avoided pressing for unnecessary details.

Clinical Follow-Up and Care Planning

• Follow-up assessment was scheduled or completed when screening indicated need
  Verify that positive or concerning screening results triggered a follow-up assessment, referral, or care plan update.
• Referrals or next steps were documented when clinically indicated
  Check for referrals to behavioral health, crisis services, social work, advocacy, or other appropriate resources.
• Safety plan or escalation pathway documented when risk was identified
  Confirm that any identified risk led to a documented safety plan, crisis response, or escalation per policy.
• Care plan reflects trauma-informed adjustments
  Review whether the care plan includes adjustments such as pacing, visit structure, communication preferences, or trigger avoidance.

Staff Competency, Quality, and Sign-Off

• Staff demonstrated trauma-informed communication and de-escalation competency
  Assess whether the staff member demonstrated appropriate tone, pacing, empathy, and de-escalation skills during the encounter.
• Any deficiencies or non-conformances were documented with corrective action
  Record observed gaps, the immediate corrective action, and the responsible party for follow-up.
• Inspector signature
  Signature of the reviewer completing this inspection.