What should be documented if a patient is judged to be at imminent risk for suicide?

When a patient is assessed to be at imminent risk for suicide, it is crucial to document the specific risk factors they exhibit, as well as the absence of any protective or mediating factors. This documentation serves multiple purposes:

First, it helps to clarify the rationale behind the risk assessment, providing a clear picture of the patient's current mental health status and the factors contributing to their risk. Identifying risk factors such as previous suicide attempts, ongoing mental health disorders, substance abuse, or significant life stressors allows clinicians to understand the urgency of the situation.

Second, noting the absence of protective factors—such as strong social support, coping skills, or a commitment to treatment—can help in formulating an appropriate intervention plan. Without adequate protective factors, the risk is elevated, and this information is vital for healthcare providers to ensure patient safety and to plan effective interventions.

By thoroughly documenting these elements, the clinician creates a robust clinical record that can enhance communication among team members, support treatment decisions, and provide valuable insight if the patient’s condition deteriorates or if they require hospitalization.