A Brief Synopsis of The Third Part of the Suicide Prevention Triangle: Detailed Documentation

Effective patient suicide prevention is composed of three interrelated facets: assessment, intervention, and documentation. Examples of free assessments include the Columbia-Suicide Severity Rating Scale (C-SSRS; available at http://cssrs.columbia.edu/) and the Substance Abuse and Mental Health Services Administration (SAMHSA) SAFE-T Suicide Assessment Five-step Evaluation and Triage (available at https://store.samhsa.gov/sites/default/files/sma09-4432.pdf). Two examples of suicide intervention programs are the Collaborative Assessment and Management of Suicidality (CAMS), a therapeutic framework in which clinicians work collaboratively with patients to develop a treatment plan that directly targets suicidal thoughts and behaviors (Jobes, 2016) and Dialectical Behavior Therapy (DBT), originally developed for individuals with borderline personality disorder. DBT has been effective in reducing suicidal behavior and self-harm in high-risk populations (Lanehan, 1993). Use of suicide safety planning is also recommended. A free version is available at https://dbhds.virginia.gov/assets/doc/bh/msmvf/brown_stanleysafetyplantemplate.pdf

The table below lays out the recommended documentation for suicide assessment and prevention. The material is taken from Simpson and Stacy (2004).

Suicide Risk Assessment Documentation

Suicide Ideation (wish to die and thoughts about attempting suicide)	Endorsement or denial
Suicide Attempt Plan	The plan details All suicide attempt methods How the attempt methods could/would be accessed.
Suicidal Intent	Endorsement or denial
Recent Suicide Attempts and Attempt History	Endorsement or denial of a nonfatal suicide attempt that occurred at some point within the past year. Number of attempts Precipitating events Attempt methods used (and how access was obtained) The patient’s attitude toward being alive following the attempt.
Risk and Protective Factors	Endorsement or denial of any suicide risk or protective factors that are discussed. Also note the risk and/or protective factors.
Safety Planning	Was a safety plan created? What did the patient/client agree to do?
Clinical Judgment	Your risk formulation with a justification informed by the patient’s history and any relevant information obtained from the risk assessment.
Recommendations/Next Steps	What are the recommendations (e.g., hospitalization) and the specific plan moving forward for the patient/client (e.g., treatment plan)?
Responses from the patient and informants	Document all attempts to contact informants. Include patient responses to assessment, formulation, and recommendation.

Simpson and Stacy (2004) posit that thorough and careful documentation of suicide risk assessments is simultaneously a best practice as well as a best defense against malpractice claims. The latter is related to legal implications of inadequate documentation, that poorly documented assessments and interventions can be seen as negligent in a court of law. They add that clear and comprehensive documentation provides some of the best evidence that clinicians have acted with appropriate care and consideration in their assessments and initial interventions.

Their guidance table [see above] covers the essential categories to consider with specific suggestions as to the related content to address. Of note, Simpson and Stacy (2004) highlight that of equal importance of what to include in suicide assessment and intervention documentation is what to avoid, for example vague or incomplete notes, failure to document follow-up plans, and neglecting to record the patient’s own statements about their suicidal thoughts.