Columbia Suicide Severity Rating Scale (CSRSS) can be used to screen and triage a patient for the acute risk of committing suicide.
Always ask:
(1) In the past month have you wished you were dead or wished you could go to sleep and not wake up?
(2) In the past month have you actually had any thoughts of killing yourself?
Ask if Question 2 is answered Yes:
(3) In the past month have you been thinking about how you might do this?
(4) In the past month have you had these thoughts and had some intention of acting on them?
(5) In the past month have you started to work out or worked out the details of how to kill yourself?
(5a) Did you intent to carry out this plan?
Always asked:
(6) In your lifetime have you done anything, started to do anything, or prepared to do anything to end your life?
(6a) In the past 3 months have you done or prepared anything to end your life?
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Question
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Positive Response Color Code
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Action
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1
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yellow
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2
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yellow
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seek behavioral health
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3
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orange
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seek behavioral health
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4
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red (high)
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get immediate help
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5
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red (high)
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get immediate help
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6
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orange
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seek behavioral health
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6a
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red (high)
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get immediate help
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Immediate help may include:
(1) calling or text 988
(2) calling 911
(3) going to the Emergency Department
Stay with a high risk patient until evaluated.
