Poor Suicide Risk Assessment Documentation Puts Patients at Risk
Documenting a patient’s risk of suicide is just as important to making a diagnosis and taking care of patients as is evaluating their vital signs.
So says a group of cross-disciplinary experts who are working to keep patients safe and keep healthcare providers from being sued for medical malpractice.
Thoughtful decision-making during the patient intake process that would help categorize that patent’s risk of suicide is only one component, however. Another is the timely documentation of this risk assessment.
The group is lobbying for balanced judgments of suicide risk to be added to the skills, knowledge, attitudes and abilities of each healthcare provider, across disciplines. Increased training can help providers in making these judgments and documentation through the process can only add to overall patient care.
Why it’s important that suicide risk assessments are documented
Patient safety is the number one priority when it comes to documenting suicide risk assessments (SRAs). Adequate documentation is also conveyed to clinicians, researchers, attorneys, a jury, or judge showing that a healthcare facility provided a certain level of care. When documentation is routine and adequate, it:
- Alerts other health care providers of the risk
- Provides indicators of treatment progress
- Serves as a checklist for treatment and care
As a procedure, documentation is widely recognized and endorsed across all healthcare settings.
By making SRA documentation routine, healthcare professionals may be able to identify suicide ideation and levels of risk in patients. In addition, patterns and spikes in suicidal behavior may be identified, allowing for early intervention and treatment.
In addition, SRA documentation showing that a suicide risk is identified, acknowledged, and addressed can mitigate liability in the event of a medical malpractice lawsuit.
When healthcare facilities fail to document an SRA and any care that was provided, they may be found liable in the event of a patient’s death or injury – even if they provided quality care. Lack of evidence, may suggest to a jury that healthcare providers didn’t meet an adequate standard of care.
What should SRA documentation include?
There are several areas that should be covered when documenting an SRA. Most importantly, this should include:
- Suicide risk factors
- Suicide ideations
- Plans and intent
- Self-harm or other alarming behavior
- Protective factors
The components included in SRA documentation should include:
- Informed consent
- Information collected from a biopsychosocial perspective
- Formulation of risk and rationale
- Treatment plans and consultations
An assessment should never be fixed, but should rather be treated as a process spanning several risk factors. An initial assessment may only reveal some risk factors, but other factors may be unveiled through further assessment and treatment. For that reason, no conclusions should be made.
Addressing insufficient training among mental health providers
We’ve established the importance of documenting SRAs, as well as the components involved. This practice can only be carried out by mental health providers with adequate training in suicide risk assessment and management.
Unfortunately, many mental health providers aren’t adequately trained to properly document SRAs. For this reason, documentation is often either absent or missing crucial details regarding patient assessment.
In one study of 339 clinical psychologists, nearly 80 percent didn’t document patients’ access to firearms. In another study of 488 veterans with a history of depression, 244 died by suicide – 70 percent of whom had no documented SRAs on file. Another study among veterans found that patients with documented SRAs (including high-quality safety plans) were less likely to experience documented suicidal behavior in the years following treatment than those with low-quality documentation.
In 2012, the National Strategy for Suicide Prevention recommended updates to suicide prevention training for healthcare professionals across the US. As of 2017, there were 43 states that had a suicide prevention plan in place – two of which had policies “mandating and encouraging” suicide prevention training among healthcare professionals. Eight of those states mandated suicide prevention education and five states only encouraged it.
Lost a loved one to suicide? Demand justice now!
While mandated suicide prevention training is a step in the right direction, it’s critical that healthcare professionals are adequately trained and prepared to provide life-saving intervention. Lacking such training or overlooking potential risk factors can be dangerous for patients.
If a patient is at risk of dying by suicide, it’s crucial for facility staff to provide adequate monitoring and take preventive measures as needed. If you’re loved one died by suicide because the healthcare professionals who treated him or her failed to assess suicide risk and provide intervention and documentation, it’s important that you discuss this matter with an experienced, compassionate Texas suicide lawyer. The Law Offices of Skip Simpson is dedicated to helping families find answers and pursue justice. We offer free and confidential consultations. You can contact us online or call (214) 618-8222.
For clinicians who want the best advice on documenting a suicide assessment, I recommend “The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors, (2011) by Dr. Shawn Christopher Shea. See Appendix A: “How To Document A Suicide Assessment.” If you follow the advice of Appendix A lives will be saved.
