FACE Risk Profile MH Adult
RA
Confidential
This form is to be completed following the assessment and/or review of risk, in accordance with local Clinical Risk Management Standards.
Written details of current and past risks/behaviour should be provided on p.2/3. This form must be photocopied onto gold coloured paper
Assessment summary
Surname:
Risk history
First name:
Is there any evidence of a history of
significant risk behaviour?
Alias::
Involvement in serious incident in past 3 months?
Gender:
No
NHS number:
Current risk status (rate using the following scale):
Title:
Care co-ordinator/Lead Professional details:
Base:
Yes
Not known
1 = Low apparent risk. No current indication of risk, but
persons history and/or warning signs indicate possible risk.
Required precautions covered by standard care plan i.e. no
special risk prevention measures or plan required.
Name:
CPA (circle)
SUI
No
0 =No apparent risk. No history/warning signs indicative of
risk.
Date of birth:
Tel:
Near miss
Yes
No
N/A
3 = Serious risk. Substantial current risk. Circumstances are
such that a risk management plan should be / has been drawn
up and implemented.
Agencies involved: (tick)
Health services
Probation services
Social Services
Police
Voluntary sector
Other (specify)
2 = Significant risk. Persons history and condition indicate the
presence of risk and this is considered to be a significant issue
at present. Requires a contingency risk management plan.
4 = Serious and imminent risk. Persons history and/or
warning signs indicate the presence of risk and this is
considered imminent. Highest priority to be given to risk
prevention.
Legal status upon assessment: (tick)
Risk of violence to others
None
On leave
Risk of suicide
Informal
s117
Risk of self-harm
Detained
Guardianship
Risk of accidental harm to self
Assessment details
Risk of severe self-neglect
Assessed by:
Risk related to physical condition
Designation:
Risk to child / vulnerable others
Date of assessment:
Risk of abuse / neglect / exploitation by others
Location of assessment:
High Risk of relapse?
Yes
No
Assessment type (tick):
Potential risk to staff members?
Yes
No
Yes
No
Initial
Review
Risk management plan developed?
Discharge
Follow-up
Further action(s) recommended/required: (tick)
Assessed in crisis situation?
Yes
Signed:
No
No further action at this stage
Further risk assessment
Discussion with RMO / team members
Date:
2000-3 FACE Recording & Measurement Systems
Date of next review:
DMHST Records Management Approved Clinical Document
Nov 2010 page 1 of 4
Service user name:
NHS number (d-o-b if not known):
Risk factors and warning signs
Time frame for all Current warning signs = past month. For all sections if No to History and Current, leave boxes in that section blank. Otherwise
place a in all boxes which apply and an X in boxes that do not apply. Enter 9 if not known or unable to assess (where risk is indicated in any
section, do not leave any boxes blank). Under Notes give brief details of recency, severity, frequency, pattern, ideation and intent.
Clinical symptoms indicative of risk
History
Current
No
No
History
Current
No
No
Notes
Early warning signs of relapse
Ideas of harming others
Ideas of self-harm/suicidal ideation
Delusions
Command hallucinations
Morbid jealousy
Impulsivity / lack of impulse control
Other
Behaviour indicative of risk
Physical harm to others
Threats/intimidation
Preparation to harm others inc. carrying weapons
Evidence of targeting (children/females/males)
Child protection issues
Suicide attempts
Plans or preparations to commit suicide
Self-harm
Domestic risk (falling, unsafe use of appliances, fire risk)
Drug/alcohol abuse
Fire-setting
Reckless or unsafe behaviour (e.g. unsafe driving)
Severe self-neglect
Absconding
Wandering
Treatment-related indicators
History
No
Current
No
Discontinuation of medication
Failure to attend appointments
Unplanned disengagement from services
Compulsory admission
Supervised discharge
Restriction order
Conditional discharge
Forensic history
History
No
Current
No
Conviction for violent or sexual offences
Special hospital
Admission to Secure unit
Admission to intensive care ward
Other involvement suggesting risk (e.g. injunctions)
Personal circumstances indicative of risk
History
No
Current
No
Family history of suicide
Physical problems/frailty (e.g. risk of falling, bed bound)
Recent severe stress
Concern expressed by others (relatives, carers)
Recurrence of circumstances associated with risk
behaviour
Abuse/victimisation by others
Social isolation
Rootlessness
2000-3 FACE Recording & Measurement Systems DMHST Records Management Approved Clinical Document Nov 2010
page 2 of 4
Service user name:
NHS number (d-o-b if not known):
Persons potentially at risk (tick as appropriate and detail below)
None
Self
Partner/spouse
Staff member
General public
Child
Parent
Group (specify)
Other (specify)
Summary of main risks identified
Have actions been taken in the past to reduce risk? (Detail, including effectiveness)
Yes
No
Unclear
No
Unclear
Service users view of risk (Give details, including persons view of what is needed to reduce risk)
Is the service user aware of possible risks?
Yes
Protective factors
2000-3 FACE Recording & Measurement Systems DMHST Records Management Approved Clinical Document Nov 2010
page 3 of 4
Service user name:
NHS number (d-o-b if not known):
Relapse and Risk Management Plan
Risk alert applied (state IT system)
Service user informed:
Agreed by:
Date applied:
If not, state why:
Review date:
Trigger signs, symptoms, behaviour suggestive of possible risk/relapse to be addressed by plan
Steps to be taken if service user fails to attend or meet other commitments (tick, detail below)
None
Send further appointment
Discuss with RMO
Contact GP
Contact care co-ordinator
Contact care manager
Contact nominated carer
Telephone
Visit home
Other (specify)
Action to be taken in the event of risk behaviour/relapse
Information sources available / accessed in completing risk profile (Tick all sources used)
Service user
Copies sent to: (tick)
Case notes
Date
Carer/relative
Other (specify)
Copies sent to: (tick)
File
GP
Care co-ordinator
Social services
User
Other
Plan completed by:
Signed:
Designation:
Date:
Signature of service user:
Date:
2000-3 FACE Recording & Measurement Systems DMHST Records Management Approved Clinical Document Nov 2010
Date
page 4 of 4