Cardiology OP Clinic Letter

**Date and Context:** [Record the date on which risk was explored] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record the setting in which risk was explored, such as in-person, phone, or video] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Identified Risk Factors:** [List all static and dynamic risk factors explicitly mentioned, including historical, psychological, social, or situational factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Ideation (I):** [Record the presence or description of suicidal ideation, self-harm ideation, intrusive thoughts, or harm-to-others thoughts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record frequency of ideation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record intensity of ideation using any explicitly stated scale or descriptor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record the explicit number of times ideation occurred, if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record duration or temporal pattern of ideation episodes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record impact of ideation on functioning, coping, sleep, work, or daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record any stated exceptions, protective contexts, or circumstances associated with reduced ideation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Intent (I):** [Record any stated intent to act on ideation or an explicit denial of intent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Plans (P):** [Describe any stated planning details, including method, timing, location, or access to means] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Actions (A):** [Record any preparatory behaviours, past attempts, recent self-harm, researching methods, acquiring means, or other risk-related actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Protective Factors (P):** [Identify internal or external protective factors such as relationships, responsibilities, values, coping skills, insight, hope, or engagement with care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Changeable Factors (Risk Modifiers):** [Record any factors explicitly identified that may increase or decrease risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record factors that may increase risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Record factors that may decrease risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Current Risk Presentation:** [Describe the current risk presentation, including ideation, intent, planning, access to means, affective state, behavioural changes, or acute triggers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Clinical Judgement and Stratification:** [State the overall clinical judgement of risk level and rationale based solely on explicitly stated information. Do not invent or infer risk level.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Immediate Actions Taken:** [Record any immediate actions taken, such as safety planning, grounding strategies, crisis signposting, escalation, safeguarding actions, or emergency responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Follow-Up Plan:** [Detail any explicitly stated follow-up actions, reviews, referrals, or planned risk monitoring] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)