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Run: Safety Planning Intervention Documentation

Document a collaborative safety plan that captures warning signs, coping steps, support contacts, means restriction, and crisis escalation in one place. Use ...

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Submission Notice

Patient consent to document this safety plan in the clinical record (required)

Confirm the patient understands what will be documented and how it will be used for care coordination and follow-up.

Yes No N/A

Purpose of this safety plan (required)

If other, describe the purpose

Completed collaboratively with the patient (required)

Indicate whether the plan was developed together with the patient rather than completed unilaterally.

Yes No N/A

Patient and Encounter Details

Patient name (required)

Date of birth

Collect only if needed to correctly identify the patient in the record.

Medical record number

Optional identifier for internal record matching.

Encounter date (required)

Encounter setting (required)

Warning Signs and Triggers

Warning signs or triggers (required)

Additional notes about warning signs

Use this field for brief context, patterns, or examples that help the patient recognize escalation.

Internal Coping Strategies and Social Distraction

Internal coping strategies (required)

People or places that provide healthy distraction

Barriers to using coping strategies

Document any barriers and how the patient agreed to address them.

Support Contacts and Professional Resources

Support contacts (required)

Professional crisis resources (required)

Preferred contact method for follow-up

Means Restriction and Environmental Safety

Means restriction discussed with the patient (required)

Yes No N/A

Agreed means restriction steps

Safe storage or temporary transfer of high-risk items agreed

Yes No N/A

Support person involved in means restriction plan

Collect only if the patient consents and it is needed for follow-up.

Crisis Escalation, Follow-Up, and Attestation

What the patient will do if coping strategies are not enough (required)

Include the agreed sequence for contacting supports, professional resources, or emergency services.

Follow-up date

Follow-up owner

Person or team responsible for follow-up outreach.

Clinician attestation (required)

Confirm the plan was reviewed, documented accurately, and entered into the record.

Yes No N/A

Clinician name (required)

Clinician role (required)

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