- Obtaining a thorough history from the client/family/SDM on admission and on an ongoing basis is important in determining the individual’s risk for injury due to falls and/or cognitive impairment.
- The use of validated tools is helpful in identifying specific client needs when planning care as the tools facilitate the specific factor assessment. Some examples include:
- Cohen-Mansfield Agitation Inventory (CMAI) for assessment of agitation
- Staff Observation Aggression Scale-Revised (SOAS-R) for aggression
- Short-Term Assessment of Risk and Treatability (START) for historical and current assessment of seven risk domains (violence, suicide, self-harm, self-neglect, unauthorized absence, substance use, and victimization)
- Broset Violence Checklist (BVC) to assess confusion, irritability, boisterousness, verbal threats, attacks on objects; or Historical-Clinical-Risk Management: 20 (HCR-20) to assess the historical and current risk for violence in psychiatric, corrections or forensic settings
- Tools for altered cognition (delirium, dementia and depression
- Tools for assessment of pain
Clinical Management
Promoting Safety: Alternative Approaches to the Use of Restraints
Sample Tools