Healthcare Safety Plan

HEALTHCARE SAFETY PLAN

Patient Information

Patient Name:   Date of Birth:

Gender:   Preferred Pronouns:

Insurance Information

Medical History

Current Diagnoses (as known):

Identified Safety Concerns

The following items summarize known or reported safety risks. Check all that apply and provide explanation as indicated.

Warning Signs and Triggers

Identify situational, behavioral, emotional, and cognitive warning signs that indicate escalation.

Coping Strategies and De-escalation

Practical actions the patient can use when warning signs appear. Include strategies the patient has found effective.

Support Network and Emergency Contacts

People who can be contacted to provide support or remove immediate danger.

Environmental and Access Control Measures

Document agreed steps to reduce access to means and improve safety of the environment.

Medication Management and Monitoring

Agreed plan for safe storage, dispensing, and monitoring of prescribed medications.

Crisis Response Plan

Clear, stepwise actions to be taken when the patient is in crisis. Include who will be contacted and when to call emergency services.

Acknowledgment, Consent, and Authorization

By signing below, the patient or authorized legal representative consents to the implementation of this Healthcare Safety Plan. The patient understands that this plan is intended to reduce immediate risk, support continuity of care, and that clinical staff may disclose limited protected health information to persons and agencies identified in this plan when necessary to prevent harm. The patient retains the right to withdraw consent at any time except where disclosure is mandated by law or professional duty to protect safety.

The patient acknowledges that:

1. Emergency services will be contacted if there is an imminent threat to life or safety.
2. Providers will document this plan in the medical record and may communicate plan elements to designated support persons and treating clinicians when necessary for safety.
3. Mandated reporting obligations (including for minors or imminent danger) may require disclosure without further consent.

Consent to share plan elements with (check all authorized recipients):

Primary support person listed in this form

Secondary support person

Primary care provider

Treating mental health clinician or team

Emergency services / first responders if immediate danger

HIPAA Privacy Acknowledgment

The patient acknowledges receipt of the provider's privacy practices notice and understands that information included in this safety plan will be maintained in the clinical record in accordance with applicable privacy laws. The patient may request restrictions on disclosure, but understands such requests may not be binding where disclosure is required to prevent harm.

Plan Review and Follow-Up

This plan will be reviewed at intervals agreed upon below or earlier if circumstances change. The reviewing clinician and next review date should be documented.

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