Risk Assessment in the Electronic Age: Application of the Circle of Caring Model

Sylvia McKnight DNP, MSN, BA, RN

This article was made possible by an educational grant from
Chamberlain College of Nursing


McKnight, S. (October 2011) Risk Assessment in the Electronic Age: Application of the Circle of Caring Model. Online Journal of Nursing Informatics (OJNI), 15 (3), Available at http://ojni.org/issues/?p=911


Mental health risk assessments are essential in providing safe quality care and optimal patient recovery outcomes. One of the challenges in mental health nursing is to develop electronic health record risk assessment charting templates to provide comprehensive assessments meeting Joint Commission on Healthcare Accreditation (JCHA) standards of care. This article details the process of developing electronic health record risk assessment templates for use in mental health facilities. The Circle of Caring Model assessment component is utilized in this article as a base for development of an electronic health record template for mental health risk assessment meeting Joint Commission requirements. The risk template’s purpose is to improve the nurse’s de-escalation skill base and meet Joint Commission mandates for a risk assessment to be completed on admission of all psychiatric patients deemed to be at risk to themselves or others to prevent harming behaviors and improve clinical outcomes.


In the profession of mental health nursing the skill of patient risk assessment is one of the most valuable tools in providing safe quality patient care (Abderhalden, Needham, Dassen, Halfens, Haung, & Fischer, 2008). In the advent of the new electronic age one of the great challenges in mental health nursing is to develop electronic health record risk assessment charting templates to provide adequate assessments meeting Joint Commission on Healthcare Accreditation (JCHA) standards. The Circle of Caring Model is a transformational model of advanced practice essential in addressing standards of risk assessment (Dunphy & Winland-Brown, 1998). The Circle of Caring Model is utilized in this article as a base for development of an electronic health record template for mental health risk assessment to meet Joint Commission requirements. With the economic downturn placing increasing stress on individuals in today’s modern society it is imperative that patient assessment of suicidal ideation and any harmful intent toward self or others be completed upon admission to all mental health facilities. Early assessment will enable development of nursing interventions to negate any harmful intent directed toward self or others and promote improvement in mental health. A detailed hypothetical case study based on utilization of the electronic risk assessment template is included. The template’s purpose is to improve the nurse’s de-escalation skill base and meet joint commission mandates for a risk assessment to be completed on admission (within 24 hours) of all psychiatric patients deemed to be at risk to themselves or others to prevent harming behaviors.

The Circle of Caring Model is a synthesized approach to practice essential for use in developing effective risk assessment templates for mental health facilities. The Circle of Caring originated from the problem solving method used in primary and acute care facilities. Features of the Circle of Caring Model include (1) a broadened and contextualized database. (2) concern labeling that actively incorporates patient responses to the meaning of illness in day to day life (3) a holistic therapeutic approach that includes nursing based interventions and complementary therapies (4) view of outcomes based on patient’s perspective of improvement (Dunphy & Winland-Brown,1998). The Circle of Caring Model includes comprehensive assessment of patient history, collaborative planning, unique nursing interventions and outcomes, evaluation addressing functional status and quality of life for holistic care.

The Circle of Caring Model emphasizes patient assessment as a vital part of nursing care. The model is utilized in the development of assessment templates incorporating both objective and subjective patient data to create the criteria areas of an electronic risk assessment template. The model encompasses critical areas of nursing including; identification and labeling of the patient illness, plan of care with nursing interventions and an outcome evaluation (Thomas, 2011). The Circle of Caring Model is a combination of the realms of nursing-based practice and the traditional medical model providing a comprehensive multiparadigm approach to nursing care (Cody, 2006). Caring acts to bridge these two domains to implement a problem solving approach to nursing care. Problem solving is a critical element of a mental health nursing administrators’ and educator’s role. The assessment component of the Circle of Caring model is utilized to develop mental health admission templates and algorithms for utilization as a guide to improve mental health assessments to enhance therapeutic care. This article will attempt to explore and utilize the assessment component of the Circle of Caring model to develop risk assessment templates to meet Joint Commission requirements and to improve mental health nursing assessment skills.

Step One – Development of De-escalation Algorithm

The first step in creating the de-escalation template is to organize a framework developed from research on Joint Commission risk assessment requirements to create an appropriate algorithm (Figure 1). Algorithm content was also received from a multidisciplinary panel consisting of mental health nurse managers and administrators. The official handbook of the Joint Commission (2008) was researched to obtain the exact requirements for the template to meet the Joint Commission mandates. The Joint Commission requires that the de-escalation assessment be completed on admission. The template needs to be incorporated as a permanent part of the electronic health record admission mental health assessment. The Joint Commission also requires the de-escalation assessment to be completed only on patients that are at risk for danger to self or others. The Joint Commission mandate gave a perfect header for placement of the template in the mental health admission assessment. A section header need only be added to the existing electronic mental health assessment stating “Danger to Self or Others” with a “Yes” or a “No” answer selection under it as seen in Figure 1. If “No” is selected the completion of the de-escalation templates will not open for completion since these templates are not necessary to be completed if the patient is not a danger to self or others. If “No” is selected the admission mental health assessment will continue as usual with no risk assessment necessary.

If “Yes” is selected in response to the question of “Danger to Self or Others” a computer template will open up offering two selections. One selection is labeled “Homicide Assessment” and the other selection is labeled “Suicide Assessment”. These are the two assessments necessary to determine specifics of imminent risks of harm to self or others (Hersen, & Turner, 1987; Zuckerman, 2005). When either of these choices are selected a full assessment template will open to be completed during the patient admission interview to determine the degree of intent of harm to self (Figure 3) or others (Figure 2). If either the homicide risk assessment of suicide risk assessment are opened a de-escalation assessment will also open subsequently. The de-escalation template will assess interventions to prevent escalation of harming behaviors.
A visualization of the algorithm is seen below in Figure 1 below.

Figure 1 – De-escalation Algorithm

Step Two – Risk Assessment Templates

Step two consists of the development of determinants of the homicide and suicide risk assessments. The Circle of Caring Model focus on assessment of psychodynamic issues was utilized to create the homicide and suicide risk assessments. Circle of Caring assessment concepts of obtaining subjective and objective data from patient history and admission assessment were utilized to develop template sections based on degree of lethality of intent to harm self or others. Research was completed on components of mental health assessments dealing with evaluation of mental illness and these aspects were combined to create the homicide assessment (Figure 2) and suicide assessment (Figure 3). A short form of homicide and suicide risk assessment were developed for this template addition for ease of electronic completion with only the most pertinent assessment criteria listed (American Psychiatric Association, 2008; Gately, & Stabb, 2005; Haggard-Grann, Hallqvist, Langstrom, & Moller, 2006). The short form template addresses the four most vital areas of psychosocial assessment. The areas consist of the presence of active thoughts of harm, plans for harm, intent to harm and means of harm to self or others as seen in the homicide risk assessment in Figure 2 and the suicide risk assessment in Figure 3. The nursing staff completing the assessment template need only check the box next to their selection then utilize the free text fill in the blank section to list verbatim decriptions of content for a comprehensive assessment of risk and lethality of intent to harm.

Figure 2 – Homicide Risk Assessment Template

Figure 3 – Suicidal Risk Assessment Template

Step 3 – De-escalation Assessment Template


The third and final step is the development of the de-escalation templates. The Joint Commission standards list requirements of assessment criteria for interventions to prevent violence or self harm and the assessment of triggers to violence and self harm. The Joint Commission criteria were implemented into the de-escalation template design. The de-escalation template selections were created by utilization of extensive research obtained from the American Psychiatric Association, American Psychiatric Nurses Asociation, National Association of Psychiatric Health Systems (2003) and the United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health Services website (2007) on the topic of de-escalation and violence prevention. Information on the most effective interventions and triggers were implemented to develop and create the templates. The purpose of the de-escalation intervention (Figure 4) assessment is to obtain vital information from the patient on personal preferences for interventions that are most effective in calming the patient when agitated or depressed to prevent self harm. The de-escalation assessment on violence triggers (Figure 4 ) assists in identifying precursors to violence that may be diminished or eliminated from the environment to prevent episodes of violence or self harm until the patient becomes emotionally stable (Austin, 2005; Chabora, Judge-Gorney, & Grogan, 2003).

Figure 4 – De-escalation Plan Assessment Template

Case Study Utilizing Electronic Risk Assessment Templates

Mr. Martin is a 43 year old well nourished white male admitted voluntarily to the behavioral health facility for complaints of depressed mood lasting over 1 year. Mr. Martin has a history of previous admissions and was discharged two months ago with a diagnosis of major depression. Mr. Martin was previously stabilized on Lexapro 10 mg daily. After questioning, Mr. Martin stated he had stopped taking his Lexapro 2 weeks ago and had begun feeling “down” and depressed. Mr. Martin arrived to the facility from a local emergency room and appears sad and despondent. An extensive mental health assessment was completed on Mr. Martin at admission. The newly created risk assessment “Danger to Self or Others” section of the admission mental health assessment was utilized and completed from information received from Mr. Martin and objective information obtained from history, lab and assessment data received from the emergency room staff. Mr. Martin was marked as a “Yes” to the question of “Danger to Self or Others” as he verbally threatened self harm and suicidal intent upon admission. The de-escalation algorithm (Figure 1) was implemented to complete a comprehensive assessment of Mr. Martin on admission to assess risk of harm to self or others.

Mr. Martin was questioned as to the presence of thoughts of self harm (Figure3). The reply from Mr. Martin was that he has having constant thoughts of suicide. The “Suicide Risk Assessment” Template (Figure 3) was selected by the admission nurse to be completed on Mr. Martin because he had threatened self harm. The information was documented verbatim on the free text line next to the question in the template. Mr. Martin was then asked if he had any plan to harm himself. Mr. Martin replied that he had a plan to obtain a gun to harm himself. The information was also documented on the line next to the question. Mr. Martin was asked if he had feelings of an actual intent to harm himself or if this was just a passive thought he would not act on. The reply from Mr. Martin was that he did have serious intent to return home and obtain a weapon to harm himself. Mr. Martin was then asked the final assessment question which was if he had any means in which to harm others. Mr. Martin replied that he had a gun hidden at home and he intended to return home to obtain it to harm himself. All four sections of the Suicide Risk Assessment template were checked as positive on Mr. Martin as this patient did have thoughts, a plan, intent and a means to attempt self harm. The severity of lethality of intent to harm was determined, documented, and reported to the psychiatrist/caregivers preventing self harm.

Since Mr. Martin was at risk for self harm the de-escalation plan assessment template (Figure 4) was also completed during his admission. When questioned about de-escalation preferences Mr. Martin stated that watching television was the only intervention that helped him to calm when he felt urges to self harm. Mr. Martin was also assessed for triggers to an agitated state. In reply he stated that loud noises agitated him. The de-escalation interventions and triggers identified in the assessment were noted in the electronic health record and placed in unit report. Nursing staff utilized the information obtained in the admission risk assessment to determine risk and interventions to prevent self harming behaviors promoting health, wellness and recovery.


The design of the risk assessments are founded in best practice and reflect established hospital policy for suicide assessment and violence prevention. One minor potential flaw of the design is that “Danger to Self or Others” must be clicked and accessed in order for the risk assessment templates to open for completion or the assessment can be missed. This minor flaw can easily be eliminated by educating both novice and advanced nursing staff on guidelines to specifically click on “Danger to Self or Others” to complete the risk assessment on every admission. In actual field trials 100% of nursing staff did open and successfully utilize the risk assessment templates after only a minimal 15 minutes of training in template utilization.

The risk assessment templates and algorithm suggested are versatile for cross-setting application in either clinical or mental health settings. The templates suggested are user friendly and have simplicity of design enabling the templates utilization with brief nursing staff training time. The addition of multiple free text fields was recommended by potential nursing staff users during field testing. The free text fields proved to be especially valuable as they allowed for expansive documentation of verbatim data obtained during the patient admission interview for enhanced assessment. The de-escalation plan was found to be especially flexible as an interventional model for prevention of suicidal ideation or homicidal/violent intent. The risk assessment templates strength is in bringing out key assessment information vital to the safety of the patient and others. Future research is still needed in the area of application of mental health assessments into electronic health records providing vital assessments safeguarding the health and safety of vulnerable populations.

The Circle of Caring is a model for holistic care. The de-escalation algorithm, de-escalation assessment and homicide/suicide risk assessments developed and based on the application of the Circle of Caring Model facilitate improvement of patient care and clinical outcomes.The templates and algorithm suggested bring out key assessment information vital to the safety of the patient and others. In application these templates will immensely improve critical mental health assessments. The electronic templates suggested not only meet the Joint Commission mandates but exceed standards for safety and therapeutic care. When effective nursing assessment tools are developed and implemented into the electronic health record mental health assessment is greatly enhanced. The result is quality care mainstreamed into the healthcare environment improving the lives and health of individuals, populations and communities as a whole.


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Author Bio

Dr. Sylvia McKnight is a career mental health educator with over 23 years of experience in nursing practice. She completed a DNP Summa Cum Laude at the University of Alabama Tuscaloosa, and holds a Master’s degree in nursing and a Bachelor’s degree in Anthropology/Psychology from the University of South Alabama in Mobile. She earned an Associate degree in nursing from Bishop State College in Mobile Alabama. Dr. McKnight’s clinical experience has included psychiatric consultation/liaison nursing and as an educator on inpatient adult and geropsychiatric units. Dr. McKnight is presently a professional mental health nursing instructor training the next generation of healthcare professionals in holistic nursing care.

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