Documenting a Suicide Risk Assessment

It is very important that when performing a suicide risk assessment in a clinical or professional context (whether a therapist, crisis or mental health worker, teacher, etc.), that you adequately document exactly what happened and what you did in response.

A good suicide risk assessment form will assist you in documenting what the suicidal person was feeling and what you, as the helper, did to help. It is not – however – a replacement for good clinical judgement. If you’re ever unsure, consult with a supervisor, seek clinical supervision or refer the suicidal person to someone with experience and training in working with suicidal persons.

Your documentation should include:

• What led to the person’s current suicidal thoughts
• The frequency, duration and intensity of suicidal thoughts
• Any preparation the suicidal person has made (putting affairs in order, stockpiling pills, etc.)
• Any previous suicide attempts and the disposition in those situations
• Protective factors that may reduce suicide risk
• The suicidal person’s view of their own risk
• Your view of the suicidal person’s risk
• What steps were put in place given the unique combination of risk and protective factors experienced by this suicidal person

If you have more information to record than is possible to fit on the suicide risk assessment that you or your organization uses, then record information on additional pieces of paper (preferably on organizational letterhead), date and sign them, and keep them attached to the originals.

Suicide risk assessments and other documents may become legal documents should a suicidal person attempt or die by suicide. Sometimes families are looking for someone to blame and so the professional that worked with them is targeted. Remember the adage, “If it’s not written down, it didn’t happen”, and record all that you feel is necessary. If at a later date you remember information, record it, along with the date that you wrote it down. Be accurate in your recollection and recording and your chances of being caught in a lie are sharply reduced.

Additionally, if your notes are ever subpoenaed, do not edit them. A common tactic by attorneys it to request the documents from the individual after they’ve already been given them through other means (from the professional College or board you are licensed under), from the organization you work for or from the client’s family) and they are looking to see if you will change details to cover your tracks. If you do, a license revocation is almost a certainty.

Retaining legal counsel and malpractice insurance may be helpful even if you don’t anticipate any problems. Consult your local Law Society for more information.