How to Document a Suicide Risk Assessment: A Checklist for Outpatient Psychiatrists

A patient can appear calm, answer questions politely and still be carrying thoughts they have told no one else. When those thoughts emerge, the psychiatrist needs to listen carefully, ask direct questions and make room for the patient to speak without feeling judged.

The conversation also needs a clear record. What did the patient share? What did the psychiatrist learn about their safety? What decisions were made, and what support was arranged? Documenting these details helps the psychiatrist return to the next appointment with an understanding of what happened today.

Meet Alex

Alex Morgan is a 34-year-old teacher attending an outpatient follow-up appointment. He talks about pressure at work, poor sleep and the recent end of a relationship. His answers are brief, and he avoids eye contact.

Then he pauses and says:

“Sometimes I feel that everyone would be better without me.”

His psychiatrist gives him time to speak. She acknowledges what he has said and asks calm, direct questions to understand what he is experiencing and assess his safety.

Alex’s words prompt a fuller assessment. The psychiatrist explores when the thoughts occur and how often, whether he has any intention or plan to end his life, whether he has access to means, and what has helped him stay safe so far. She also considers his symptoms, recent stresses, previous behaviour and the people he can turn to for support.

Step 1: Record why the assessment was completed

Begin by documenting what prompted the suicide risk assessment.

In Alex’s case, the reasons include:

• A statement suggesting a passive wish to die
• Worsening depressive symptoms
• Hopelessness
• Relationship separation
• Work-related stress
• Poor sleep and increasing social withdrawal

The documentation might read:

“A suicide risk assessment was completed after the patient reported passive thoughts that others might be better without him, together with worsening depression and hopelessness.”

This provides context. It shows that the assessment was connected to information obtained during the consultation rather than being an isolated checklist.

Step 2: Describe the suicidal thoughts clearly

Terms such as “suicidal,” “positive” or “high risk” are not detailed enough on their own.

Document:

• Whether the thoughts are passive or active
• When they began
• How often they occur
• How long they last
• When they occurred most recently
• Whether their frequency or intensity has changed
• What was happening when the thoughts appeared
• How controllable the patient feels they are
• What stops the patient from acting on them

Alex explains that the thoughts began approximately two weeks ago. They usually appear late at night when he feels alone. They occur several times each week and last for a few minutes.

He describes them as thoughts of not wanting to wake up, rather than an intention to end his life.

A clear note could say:

“The patient reports passive thoughts of death several times per week for approximately two weeks, usually when alone at night. He denies current active suicidal thoughts and describes no intention to act on these thoughts.”

Direct, neutral language makes the record easier for another clinician to understand.

Step 3: Assess current intent

Intent and thoughts are related, but they are not the same.

The psychiatrist asks Alex whether he currently intends to end his life. She also explores whether he expects that he may act on the thoughts in the near future.

Document whether intent is:

• Present
• Denied
• Unclear
• Fluctuating
• Unable to be reliably assessed

Alex denies current intent. He says the thoughts frighten him and that he wants help.

The record might state:

“The patient denies current suicidal intent and denies expecting to act on the thoughts. He is seeking support and agrees to participate in safety planning.”

Avoid documenting “no risk” simply because the patient denies intent. The final judgement should consider the complete clinical picture.

Step 4: Ask about a plan and access to means

The assessment should directly explore whether the patient has considered a method, formed a specific plan, taken preparatory steps or has access to potentially lethal means.

NIMH guidance recommends asking about a suicide plan and access to means even when other responses appear reassuring.

Document:

• Whether a specific plan exists
• How detailed or developed it is
• Whether preparatory behaviour has occurred
• Whether relevant means are accessible
• Whether access has recently changed
• What safety actions were discussed or completed

Alex denies having a method or plan. He reports no preparatory behaviour and no identified access to means connected with suicide.

The note could say:

“The patient denies a specific suicide plan, preparatory behaviour or identified access to means. Lethal-means safety was discussed as part of the risk-management plan.”

Do not document unnecessary operational details. Include only the clinically relevant information needed to support assessment and care.

Step 5: Document previous attempts and self-harm separately

A previous suicide attempt and non-suicidal self-injury are not interchangeable.

Ask about:

• Previous suicide attempts
• Approximate dates and circumstances
• The patient’s intent at the time
• Medical consequences
• Treatment received
• Interrupted or aborted attempts
• Preparatory behaviour
• Non-suicidal self-injury
• Recent changes in self-harm behaviour

Alex reports no previous suicide attempts. He describes one episode of superficial self-injury at age 19 but says he did not intend to die.

The psychiatrist documents:

“No previous suicide attempts reported. The patient describes one episode of superficial self-injury at age 19 without suicidal intent. No recent self-harm.”

Past suicidal behaviour is a particularly important risk factor and should not be reduced to a simple yes-or-no entry without relevant context.

Step 6: Record current risk factors

Risk does not come from a single symptom or score. It is formed by the interaction of current circumstances, psychiatric symptoms, history and access to support.

For Alex, the psychiatrist records:

• Worsening depressive symptoms
• Hopelessness
• Recent relationship loss
• Occupational stress
• Poor sleep
• Increasing isolation
• Passive thoughts of death
• A remote history of non-suicidal self-injury

Other relevant areas may include:

• Previous suicide attempts
• Substance use or intoxication
• Agitation or impulsivity
• Psychosis
• Mania
• Severe anxiety
• Chronic pain or serious illness
• Financial or legal problems
• Recent discharge from inpatient care
• Family history of suicide
• Sudden loss of support
• Treatment disengagement

Document only what was assessed and clinically relevant to the individual patient.

Step 7: Give protective factors equal attention

Protective factors are not decorative additions to the note. They help explain the patient’s current situation and inform the safety plan.

Alex identifies:

• A close relationship with his daughter
• Support from his sister
• Stable housing
• Continued employment
• Willingness to receive treatment
• Future plans
• A desire to recover
• Ability to seek help

The note might say:

“Protective factors include a close relationship with his daughter, regular contact with his sister, stable housing, employment, future orientation and active engagement with treatment.”

Protective factors do not automatically cancel risk factors. Their strength, reliability and availability should be considered in context.

Step 8: Include the relevant Mental Status Examination

The Mental Status Examination should support the clinical formulation rather than sit separately as unrelated information.

For Alex, the psychiatrist records:

• Appearance: appropriately dressed and well groomed
• Behaviour: calm and cooperative
• Eye contact: reduced when discussing suicidal thoughts
• Speech: quiet but clear
• Mood: “very low”
• Affect: constricted but reactive
• Thought process: linear and goal-directed
• Thought content: passive thoughts of death; no current intent or plan
• Perception: no hallucinations reported
• Cognition: alert and oriented
• Insight: good
• Judgement: intact during the assessment

Document abnormalities and relevant normal findings. Avoid vague statements such as “MSE normal” when individual findings influenced the risk decision.

Step 9: Connect the formulation to an agreed plan

A formulation should explain what is making safety difficult now, what has changed or could make things worse, what helps, and how that shared understanding informs the next steps. It should make the psychiatrist’s reasoning and the person’s own perspective clear.

It should connect:

• Current suicidal thoughts
• Intent and planning
• Previous behaviour
• Acute and longer-term risk factors
• Protective factors
• Mental state
• Reliability of the information
• Available support
• Likely changes that could increase risk

For Alex, a narrative formulation could read:

“Alex presents with worsening depressive symptoms, hopelessness and passive thoughts of death in the context of relationship separation and occupational stress. He denies current intent, a specific plan, preparatory behaviour and access to identified means. He has no history of suicide attempts but reports remote non-suicidal self-injury. Protective factors include his daughter, supportive sister, stable housing, employment, future plans and willingness to engage in care. Alex identifies poor sleep and withdrawing from his sister as signs that his safety may be worsening. These supports matter to his plan, but do not remove the need to respond to his current difficulties.”

About the previous “moderate risk” wording: it was an example of terminology used in some services, not a universal documentation requirement or a prediction of future behaviour. The earlier reference to The Joint Commission reflects a United States accreditation context; it should not be read as an England-wide rule. Standards change, and documentation requirements vary by jurisdiction and service, so check the current standard that applies to your setting.

In England, NICE guideline NG225 says not to use global low, medium or high risk categories to predict suicide or self-harm, or to decide who receives treatment or is discharged. It directs assessment toward the person’s needs and immediate and longer-term safety. NHS England’s Staying safe from suicide guidance describes a collaborative approach to safety assessment, formulation and planning. Follow the relevant local pathway and professional guidance.

England example: link the formulation to actions

The following adult outpatient example is illustrative, not a recommended disposition or a fixed follow-up interval. The clinician would agree actions with Alex based on the full assessment, his preferences, local services and the applicable care pathway.

Shared understanding: Alex describes passive thoughts of death several times a week, usually when alone at night. Poor sleep, relationship separation and work pressure are contributing difficulties; he notices that he withdraws from his sister when things worsen. He reports no current intent, plan or preparatory behaviour. His daughter, supportive sister, stable housing, future plans and willingness to engage in care are supports he identifies. The conversation focuses on how these circumstances affect his safety now and what may change, rather than assigning a global category.

Agreed actions and responsibilities:

• Alex: keep a copy of the written safety plan, use the warning signs and coping steps he chose, and contact his sister or the agreed urgent support service if he feels less able to stay safe.
• Alex and his sister, with Alex’s consent: agree that she will check in by phone each evening for the next three days. Alex can choose a different support person or decline this involvement.
• Clinician: review the plan with Alex before he leaves, discuss safe storage of medicines and any other means identified in the assessment, write the agreed urgent contact details into the plan, and send an agreed update to his GP today.
• Clinician: telephone Alex tomorrow to review his thoughts, sleep, isolation and use of the plan, then see him again in three days. If the assessment indicates that outpatient care is not sufficient, arrange urgent support through the local pathway rather than waiting for these appointments.

Alex and the clinician record what should prompt earlier help and who to contact. In England, urgent mental health support is available through NHS 111’s mental health option; local pathways may also identify a crisis team or other service. If there is immediate danger to life, use emergency services or attend A&E. The clinician documents the agreed review time, what will be reassessed, and what Alex should do if his situation changes before then.

These timings are examples, not a rule. A safety plan does not guarantee safety or replace urgent assessment when needed. Revisit the formulation and actions as the person’s circumstances and needs change.

Step 10: Create a collaborative safety plan

A safety plan is more than telling the patient to seek help if things become worse.

It should be practical, personalised and developed with the patient. VA guidance describes safety planning as a collaborative, patient-centred intervention containing clear steps a person can use during increasing distress or a suicidal crisis.

A safety plan commonly includes:

1. Personal warning signs
2. Internal coping strategies
3. People or places that provide distraction
4. Trusted people the patient can contact
5. Professional and crisis-support contacts
6. Steps to reduce access to lethal means

Alex identifies his warning signs as lying awake, withdrawing from his sister, missing work and feeling that he is a burden.

His coping steps include taking a walk, listening to familiar music and moving into a shared space rather than remaining alone.

He agrees to contact his sister if the thoughts become stronger. The psychiatrist confirms the appropriate professional and emergency contacts and discusses reducing access to potentially dangerous items.

The record should state what was actually agreed:

“A collaborative safety plan was reviewed and updated. The patient identified warning signs, coping strategies and his sister as a primary support. Crisis and emergency options were discussed. Lethal-means safety was reviewed. The patient received a copy of the plan and was able to explain how he would use it.”

Safety planning should not be treated as a guarantee of safety or a replacement for appropriate clinical intervention.

Step 11: Document the disposition and immediate plan

The record should clearly show what happens after the assessment.

Possible actions may include:

• Emergency evaluation
• Transfer to a higher level of care
• Consultation with another clinician
• Involvement of a support person, where appropriate
• Medication review
• Increased appointment frequency
• A telephone check-in
• Referral for therapy or another service
• Updated safety planning
• Crisis information
• Specific instructions for worsening symptoms

Alex does not currently report intent, a plan or preparatory behaviour. He is engaged, help-seeking and has accessible support. Based on the complete assessment, the psychiatrist decides to continue outpatient care with closer monitoring.

The plan is documented as:

“Continue outpatient management with increased monitoring. Safety plan updated. Medication response and adherence reviewed. Telephone check-in arranged for the following day, with an in-person appointment in three days. The patient was advised to use emergency services immediately if suicidal intent develops, a plan emerges or he is unable to maintain his safety.”

If the patient is at immediate risk, outpatient documentation should never delay urgent intervention.

Documenting When a Referral or Psychiatric Bed Is Unavailable

Sometimes a new assessment indicates that urgent specialist evaluation is needed, but the preferred service cannot accept a referral or has no inpatient bed available. Record the clinical need, each contact and response, any reassessment while arrangements are made, and the final handover and disposition. Bed availability is a service constraint; it does not by itself establish that discharge or outpatient care is clinically appropriate. The next step must be based on the current assessment and the applicable local pathway.

Fictional continuation: Alex at a later appointment. Alex now describes worsening suicidal thoughts and increasing difficulty maintaining his safety. After reassessing his current presentation and available support, his psychiatrist determines that urgent emergency psychiatric evaluation is needed. The preferred inpatient service reports that no bed is available.

Using Dr. Notes to record the example

The screenshots below use fictional information entered in the Dr. Notes Psychiatry App. The Safety section holds the current findings, protective factors and narrative safety notes. In Assessment & Plan, the clinician can record the referral response and consultation, then use the structured plan fields for safety planning, follow-up and disposition. These fields support documentation; the clinician still assesses the person, chooses the action and confirms that every entry reflects what occurred. The Therapy Note Builder is for therapy progress notes, so it is not the tool shown in this psychiatric example.

For this illustration, the psychiatrist then consults the local crisis service. After hearing the updated assessment, the crisis clinician advises urgent assessment through the emergency department while the inpatient referral remains active. The outpatient psychiatrist agrees to arrange the next step through the local pathway and give a direct handover.

Record referral attempts and consultations

For each attempt, record the service contacted, the date and time, the name or role of the person responding, the relevant information shared, the response and why the referral could not proceed. Include any alternative offered, expected wait if known, and what the clinician agreed to do next. Document consultations with the receiving emergency team, crisis service or another psychiatrist in the same way: recommendations, agreed responsibilities and who will make the next contact.

Illustrative entry: “At 14:05, I contacted [preferred inpatient service] and spoke with [name/role]. The service reported that no bed was available and could not accept a transfer at that time; no estimated availability was given. At 14:20, I discussed Alex’s presentation and need for urgent evaluation with [receiving emergency/crisis clinician and role]. They advised [recommendation]. We agreed that [receiving person/service] would [action] and that I would [handover or other action].” Replace each bracketed item with what actually happened.

Document reassessment and interim arrangements

If the person is waiting for assessment or transfer, document reassessments as they occur and whenever the presentation changes. Record the findings actually assessed, the time, any additional consultation, and the interim safety or support measures agreed, including who is responsible for each action. If the situation changes or arrangements are delayed, contact the relevant service again and document the new advice and decision. Follow local policy and clinical judgment for the urgency and frequency of reassessment; this example does not set a universal interval.

Record the final disposition and clinical reasoning

In Alex’s example, the psychiatrist arranges urgent emergency psychiatric assessment through the local pathway and documents the handover to the receiving team. The note states why that step was chosen based on the reassessment and consultation: Alex’s thoughts have worsened and he reports increasing difficulty maintaining his safety, so urgent evaluation remains indicated. It also records what interim arrangements were made, who is responsible until the receiving service takes over, and whether the inpatient referral remains active. The preferred bed remains unavailable, but that fact alone does not resolve the clinical need for urgent assessment. If another disposition is selected, document its clinical rationale, the alternatives considered, consultation, safety arrangements and specific follow-up. Do not present a safety plan as a substitute for urgent intervention when the assessment indicates it is needed.

This is a documentation example, not a triage or transfer protocol. Referral routes, legal duties and service processes vary; use the current local pathway and record the decisions made for the individual patient.

Step 12: Make the follow-up specific

“Follow up soon” is not a complete plan.

Document:

• The date or time frame
• The type of contact
• Who is responsible
• What will be reassessed
• What the patient should do if their condition worsens
• Whether support people or other clinicians were contacted
• Any barriers to follow-up

For Alex:

“Telephone review tomorrow to reassess suicidal thoughts, intent, sleep and use of the safety plan. In-person follow-up scheduled in three days. The patient agrees to contact the clinic earlier or use emergency services if risk increases.”

Specific follow-up creates continuity and allows the next clinician to understand exactly what was planned.

Suicide Risk Assessment Documentation Checklist

Before completing the note, confirm that the following areas are addressed:

Reason for assessment

• Trigger for the assessment
• Patient’s own words where clinically helpful
• Changes from the previous visit

Suicidal ideation

• Passive or active thoughts
• Frequency, duration and most recent occurrence
• Intensity and controllability
• Current thoughts

Intent, plan and means

• Current intent
• Specific plan
• Preparatory behaviour
• Access to means
• Lethal-means safety discussion

History

• Previous suicide attempts
• Interrupted or aborted attempts
• Non-suicidal self-injury
• Relevant treatment following previous events

Clinical context

• Psychiatric symptoms
• Substance use
• Recent stressors or losses
• Relevant medical concerns
• Mental Status Examination
• Reliability of information

Risk and protection

• Acute and longer-term risk factors
• Protective factors
• Support network
• Reasons for living and future orientation

Clinical judgement

• Narrative formulation of the person’s current safety difficulties
• Precipitating and protective factors, including what may change
• How the formulation informs the chosen care and management plan
• Agreed actions, the person responsible and when each will happen
• Review timing, what will be reassessed and how to seek earlier help

Safety and follow-up

• Collaborative safety plan
• Crisis and emergency instructions
• Involvement of supports, when appropriate
• Treatment changes
• Follow-up date and method
• Reassessment plan

How Dr. Notes for Psychiatrists can support the process

A suicide risk assessment requires careful listening. Documentation should support that conversation rather than pull the psychiatrist away from it.

The Safety and Risk area within Dr. Notes for Psychiatrists helps organise relevant information such as:

• Suicidal thoughts
• Passive death wishes
• Current intent
• Specific plan
• Access to means
• Previous attempts
• Self-harm
• Harm to others
• Other acute concerns
• Protective factors
• Clinical safety notes

The wider psych evaluation connects the safety assessment with symptoms, history, Mental Status Examination, clinical formulation, assessment, treatment planning and follow-up.

Before completing the evaluation, the psychiatrist can review the information together, correct or clarify entries and create a clear final note for the next visit.

Dr. Notes supports structured documentation. It does not calculate certainty, predict an individual patient’s behaviour, diagnose the patient or replace clinical judgement.

Clear documentation supports connected care

Alex leaves the appointment with more than advice.

He leaves with a plan he helped create, a sister he has agreed to contact, a telephone review scheduled for the next day and another consultation already arranged.

His psychiatrist leaves with a clear record of what Alex said, what she assessed, why she selected outpatient management and what actions were taken.

That is the purpose of good suicide risk documentation. It is not simply about completing fields or protecting a record. It is about preserving the reasoning, decisions and human conversation behind the care.

Dr. Notes for Psychiatrists helps keep that information organised, so the psychiatrist can return to the next consultation with the right context—and Alex does not have to begin his story all over again.

Learn more: Dr. Notes for Psychiatrists