Documenting suicide risk assessments and proportionate clinical actions to improve patient safety and mitigate legal risk

Abstract

Few clinical practices are as important for simultaneously augmenting patient safety and mitigating legal risk as the judicious evaluation and stratification of a patient's risk for suicide, proportionate clinical actions based thereon taken by the healthcare provider, and contemporaneous documentation of the foregoing. In this article, we draw from our combined decades of multidisciplinary experience as a clinical psychologist, forensic psychiatrist, medical malpractice attorney, and clinical psychology trainee to discuss the documentation of suicide risk assessment and management as a conduit to patient safety and legal risk mitigation. We additionally highlight documentation as a core clinical competency across disciplines and note areas of improvement, such as increased training, to bolster documentation practices.

PROTECT: Relational safety based suicide prevention training frameworks

“…The focus is on capturing the suicidal N arrative, detailing the risk and interplay of dynamic factors. Symptoms both present and absent need to be captured (Stanley et al , ), and the DESPAIR prompts help with this. O ptions appraisal displays the pros and cons of all the available alternatives including hospitalization (Jobes, ).…”

Teaching dialectical thinking to enhance graduate trainees’ competence in outpatient psychotherapy for adolescents experiencing suicidal thoughts and behaviors.

“…As is true of all interventions, psychotherapists are ethically and legally obligated to maintain adequate treatment records when providing outpatient care to youth experiencing STBs (ACA, 2014; APA, 2017; CCPA, 2007; CPA, 2017). In this area of clinical practice, it is particularly crucial to document: (a) the agreements that were reached as part of informed consent, (b) assessment of risk of STBs, including bio-psycho-social risk and protective factors influencing this determination, (c) immediate and long-term actions taken to mitigate this risk (e.g., the treatment and safety plan), (d) plans for re-assessing risk of STBs, (e) communications with the youth and caregivers about the treatment plan, and (f) any consultations about the case (Cramer et al, 2013; Rudd et al, 2008; Simpson & Stacy, 2004; Stanley et al, 2019). At each point of decision-making, psychotherapists should also document other options that were considered and why the final decision was selected over alternatives (Stanley et al, 2019).…”

Suicide in primary care: How to screen and intervene

“…First, it improves patient safety by ensuring all components of the risk assessment are available for future use and accountability. 25 Second, good documentation helps to reduce legal liability in the event a patient dies by suicide. With modern electronic medical records the note can be at least partially completed contemporaneously while assessing the patient.…”