“Client denied suicidal ideation.”
“Client reports suicidal ideation but lacks plan or intent.”
“Client reported only mild suicidal thoughts.”
Many clinicians use these phrases in their clinical notes – and then say nothing else about suicide risk. Such minimalism is not good practice, for either the clinician or the client.
Good documentation enables the therapist to think through his or her clinical decisions in writing and to maintain a record of treatment that other professionals working with the client (now or later) can see. These aspects of documentation clearly benefit the client.
Documentation also, if done right, protects the therapist from losing a malpractice suit if appropriate care was provided.
“If it’s not written down, it didn’t happen.” This is a common saying when discussing documentation. Clinicians need to document their decision-making process in order to justify their actions.
Writing It in Stone
When a client dies by suicide, many families will ask, “What did the therapist do more to stop this from happening?” If the family hires an attorney and sues you, the answer to their plaintive question needs to be in the client’s chart.
The family might also ask, “Why didn’t the therapist do more?” Perhaps the client insisted that she did not have suicidal thoughts, or that she would not act on such thoughts. It needs to be documented.
And, of course, such documentation needs to have been completed immediately or shortly after the appointment is finished, and any changes or additions must be clearly labeled and dated.
Fears of Documenting Suicide Risk
Some therapists may find it frightening to document that the client is thinking of suicide. “Now if something happens, it will be on the record that I knew he was suicidal and I didn’t do enough,” the thinking might go.
This line of reasoning is faulty. One, to practice ethically and competently, we must portray our clients’ situations accurately. That means if they have suicidal thoughts, our records must reflect that. Two, as long as we document our decision-making and it is sound, then we have protected ourselves.
What to Write
Good, thorough documentation of work with a suicidal client should include the following:
- Suicide risk assessment, to include (at a minimum):
- Desire to die
- Suicidal ideation (frequency, intensity, duration)
- Plan for suicide attempt (e.g., methods considered)
- Means to carry out plan
- Intent to act on suicidal thoughts
- Timing of planned suicidal acts
- Any preparations taken for suicide
- Reasons for wanting to die by suicide
- Reasons for not wanting to die by suicide (e.g., reasons for living, protective factors)
- Prior history of suicide attempt, which is the biggest risk factor for suicide, as well as any history of suicidal thoughts
- Inquiries about firearms and other lethal means available to the client
- Efforts to have lethal means removed from client’s environment
- Safety plan agreed upon with client
- Categorization of level of suicide risk (e.g., low, medium, high, imminent), with rationale
- Rationale for treatment decisions, based on suicide risk assessment (including actions not taken)
Document, too, if you consulted with other professionals or if you sought corroborating information from significant others, as well as what they said.
Of course, the above areas for suicide risk assessment are in addition to all basic areas for assessment, including a client’s presenting problem, alcohol and other drug use, mental illness, trauma, family history of suicide and mental illness, and other risk factors for suicide.
If you do these things with your clients – and if you write them down in the clinical record – then you are protecting, in different but important ways, both the client and yourself.
© Copyright 2013-2015 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide
Revised April 30, 2015
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