A Brief Synopsis of The Third Part of the Suicide Prevention Triangle: Detailed Documentation
Stewart E. Cooper, Ph.D., ABPP
September 13, 2024
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.
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About the Author
Stewart E. Cooper, Ph.D., ABPP
My diverse professional background in psychotherapy practice, education, supervision, and research have worked synergistically with each element enhancing the others. For many years, I served as the Director of Counseling Services (which eventually included a Counseling Center plus separate Substance Abuse, Sexual Assault and Suicide Prevention units) at Valparaiso University in NW Indiana. During this time, I was also a faculty member in the Department of Psychology teaching in their accredited master’s mental health counseling program where I served two stints as its Program Chair. Based on my teaching, service, and scholarship, I was promoted to Full Professor. I have authored/edited 5 books, 10 book chapters, and 100 refereed journal articles. Within APA Governance, I have served as the Chair of the Board of Professional Affairs, Chair of the Membership Board, a member of its Policy and Planning Board and as co-creator and member of its Committee for the Advancement of General Applied Psychology. I also served two terms on its Council of Representatives and was an At-Large Member of the APA Board of Directors. Additionally, I was President of the Society for Consulting Psychology (APA Division 13) and am President-Elect for the Society for the Advancement of Psychotherapy (APA Division 29). Licensed as a HSPP in Arizona and in Indiana with Board Certification in both Counseling and Organizational Psychology, I am currently expanding Life Enrichment Associates, a solo clinical and consultation practice which I developed in 1982.
Citation
References
Jobes, D. A. (2016). Managing suicidal risk: A collaborative approach (2nd ed.). The Guilford Press.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. The Guilford Press.
Simpson, S., & Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicide risk assessment. Journal of Psychiatric Practice, 10(3), 1-5.