UW HEALTH CLINICAL POLICY 1
Policy Title: Suicide Evaluation and Intervention for Ambulatory Patients
Policy Number: 2.4.4
Category: UW Health
Effective Date: October 25, 2016
To establish a process for UW Health staff to evaluate and provide intervention strategies for the potentially
suicidal ambulatory patient who presents via telephone call or electronic communication to any UW Health
department, including University Hospital Psychiatry Unit, or in-person at a UW Health location.
For UW Health admitted patients and Emergency Department patients, refer to UW Health clinical policy
#2.4.1, Suicide Assessment and Prevention.
Patient: For the purposes of this policy, “patient” refers to any person that calls, sends an electronic
communication, or presents in-person to a UW Health department.
Appropriate clinician: A registered nurse, social worker, or behavioral health specialist who is qualified to
perform a suicide risk evaluation.
III. POLICY ELEMENTS
A. All suicide threats or attempts, regardless of apparent triviality, should be taken seriously. Any suicide
situation should be considered a potentially life-threatening event.
B. Any patient, whether in person, by electronic method, or on the phone, who expresses suicidal thoughts or
threats and/or demonstrates any behavior suggestive of suicidal intent, will be evaluated immediately by an
appropriate clinician, if available.
i. If the patient presented in person:
a. Immediately assist the patient to a quiet area and find an appropriate clinician to speak
with the patient, if available.
b. If no appropriate clinician is available, call 911 or if at a hospital building location, call the
appropriate emergency response team. Refer to UWHC policy #7.36, Emergency
ii. If the patient presented via an electronic communication:
a. An appropriate clinician should call the patient immediately upon reviewing the message.
Refer to the Ambulatory Service Standards.
iii. If the patient presented on the phone:
a. Keep the patient on the line, if possible, and find an appropriate clinician to speak with the
b. If no appropriate clinician is available, keep the patient on the line, if possible, and call
iv. If the clinician performing the suicide risk evaluation is concerned for the patient’s immediate
safety, the clinician should call 911 or if at a hospital building location, call the appropriate
emergency response team.
i. Complete a PSN in the following situations:
a. If 911 is called.
b. If the patient attempts/completes suicide.
c. If the patient who is expressing suicidal thoughts is not a previously registered UW Health
d. If the only responding staff person is unable (i.e., does not have the necessary Health Link
security) to document in the patient’s medical record.
ii. If the responding staff person did NOT perform a suicide evaluation but is able to document in the
patient’s electronic medical record:
a. Document in Health Link the conversation and actions taken.
iii. If the responding staff person performed a suicide evaluation:
UW HEALTH CLINICAL POLICY 2
Policy Title: Suicide Evaluation and Intervention for Non-Admitted Patients
Policy Number: 2.4.4
a. Document in Health Link the conversation, advice given, and who else was contacted
regarding the care of this patient, including the occurrence of a verbal (“warm”) hand-off to
the Emergency Medical Services (EMS), Police, and/or the receiving Emergency
Department, if applicable.
Author: Director, UW Health Behavioral Health Services
Senior Management Sponsor: Chief Ambulatory Administrative Officer
Reviewers: PhD, Psychiatry, Immediate Treatment Clinic; MD, Psychiatry; Patient-Family Connections
Director; Mental Health Case Management Administrative Program Director; RN Clinical Staff Educators
(UWMF & UWHC); Manager, Social Work & Spiritual Care; Clinical Operations Manager, Psychiatry –
General; Quality Care Coordinator – Health Promotion; Inpatient Psychiatry, CNS; RN, Triage Healthline
Approval committee: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: August 15, 2016
UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.
Peter Newcomer, MD
UW Health Chief Medical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
UW Health clinical policy #2.4.1, Suicide Assessment and Prevention
UWHC policy #7.36, Emergency Response Teams
UW Health administrative policy #4.22, UW Health Event Reporting
Ambulatory Service Standards
VII. REVIEW DETAILS
Next Revision Due: October 2019
Formerly Known as: UWHC Ambulatory departmental policy #8.14, Suicide Assessment and Intervention in
Clinic; UWMF, Person at Risk for Suicide