Documenting Risk Assessment & Safety Decisions

1. Document the assessed findings

• Passive death wishes versus active suicidal thoughts, with frequency, intensity, duration, recency, and controllability rather than a bare statement that risk is present or absent.
• Intent, plan, timing, access to means, and preparatory behavior.
• Prior attempts, interrupted/aborted attempts, and self-injury with the intent associated with each.
• Current stressors, agitation, intoxication, psychosis, hopelessness, and other relevant acute drivers, including onset or trajectory when it is clinically meaningful.
• Meaningful deviation from baseline in sleep, eating, hygiene and self-care, daily functioning, cognition, and behavior, described specifically enough that another clinician can see what changed.
• Whether the person can still hold a workable safety arrangement, and what makes that judgment credible.
• Protective factors and whether they are actually available now.
• Collateral information that materially informed the assessment, including any discrepancy with self-report.

2. Show the formulation, not just a label

• Describe acute concern, longer-term vulnerability, and the change from baseline.
• State the factors that increased concern and the factors that made the proposed disposition feasible or not feasible.
• Document uncertainty when it mattered. Do not convert uncertainty into a falsely precise score or absolute declaration of safety.

3. Record the intervention that actually happened

• Safety-plan development or review and the client's participation.
• Means-safety discussion and the specific arrangement, including who will secure what and when when applicable.
• Support/caregiver involvement, consent or emergency disclosure basis when relevant, and the task the support person agreed to perform.
• Crisis service, ED, mobile crisis, 988, 911/EMS, or other referral/activation and whether a receiving service actually accepted the handoff.

4. Document consultation when it changed the plan

• Who was consulted and their role.
• The clinical question brought forward.
• Material recommendation or decision that resulted.
• How the recommendation changed or confirmed the disposition/follow-up plan.

5. Make disposition and ownership explicit

• Why outpatient follow-up, urgent evaluation, emergency response, or another disposition was selected.
• Who is responsible for the next contact, referral, reassessment, or handoff confirmation.
• The planned timeframe and what should trigger earlier escalation.
• For telehealth or urgent transfers, record location, destination, transport, accepting service/person when known, and disconnection/reconnection actions when relevant.

6. When someone leaves during an urgent concern

Record what was actually done and observed. Do not document a pursuit, a welfare determination, or a resolution that the clinician did not have the authority, information, or safe opportunity to complete.

• The point at which the person left, what was occurring clinically, and the concern active at that moment.
• Last known location, direction of travel, and identifying or vehicle information relayed to responders.
• Which emergency or crisis service was contacted, what was reported, and what the responder indicated would happen.
• Reconnection and outreach attempts, including calls, secure messages, and lawful contact with an identified support person.
• Supervisor notification, what remains unknown, and who owns follow-up until the situation is resolved.

Avoid documentation shortcuts

• Do not write 'no risk' when the assessment supports a more specific formulation.
• Do not write 'client contracts for safety' as a substitute for assessment and safety planning.
• Do not copy forward means access, protective factors, caregiver availability, or intent findings without reassessing them.
• Do not document actions, consultations, reports, or handoffs that did not occur.