5 key components of chart documentation
- Risk factors
- Protective factors
- Collateral information
- An estimate of the patient’s suicide risk
- A plan
- Risk factors or warning signs that may increase the chance of suicide.
- Protective factors that may decrease the chance of suicide.
- Collateral information.
- An estimate of the patient’s suicide risk. Low, medium, or high. The word estimate is not an accident. We can estimate but not predict future suicide. Predicting suicide is essentially impossible. That is an important point to remember throughout the process and communicate with the patient and their family. When I’m finished with my assessment and start talking about disposition, I say something like this, “All these questions I’m asking are helping me estimate suicide risk. I think the risk is X because of this…” (and go through the reasons.) I make it clear that there is no certainty in the process and that we’re all in it together, not just the patient and me, but the family, friends, and providers. Don’t get pigeonholed into low, medium, or high. because suicide risk is a continuum. The risk estimation is based on a compendium of parts including: risk and protective factors, extent of support, collateral information, change of condition in the ED (better or worse), and your clinical judgment of the whole picture.
- The plan: If they’re being discharged, the follow up and alternatives to self harm should the patient have difficulty coping or feel compelled toward suicide. If it’s an admission, the rationale as to why you think it’s a better option than discharge and outpatient management. Put in a line about how you think the disposition plan mitigates immediate suicide risk, such as, “The patient is being discharged with his brother who will stay with him for the next few days and will begin intensive outpatient treatment starting on Monday. If he feels he is becoming unsafe, instead of acting on an impulse of self harm he will contact the crisis line, speak to his brother about it, or return to the emergency department. There is a gun in the home which has now been removed. I feel this plan further mitigates his suicide risk.” If possible, partner with the family in the discharge planning.23 Nowhere in the plan should you mention contracts for safety.5 That phrase does not protect the patient and it does not protect you medicolegally.
Example of suicide risk assessment paragraph:
Mr. X presents with multiple risk factors including daily drug use, depression with a sense of hopelessness and a concrete plan to hang himself, which he tried to hide. He had cleared space in his garage to carry out the hanging and was disappointed when the setup was discovered by his girlfriend.
He also has limited social support and a chronic medical illness which limits his ability to work.
There are some protective elements such as a willingness to engage in the therapeutic process. He also does not seem to be withholding information and shows no signs of agitation or psychosis. He does, however, demonstrate debilitating anxiety which has been unresponsive to treatment in the ED.
I spoke with his mother who reports that Mr. X has been making suicidal statements over the past few days with increasingly erratic behavior. Considering the above, my conservative estimate of this patient’s suicide risk is high and I feel he warrants hospitalization.