Registered Nurses' Association of Ontario

Using Validated Assessment Tools

  • 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