Proper suicide assessment is probably the most important part of a clinician's job; appropriately, heavy emphasis is placed on this in our education. Unfortunately, psychiatrists receive comparatively little practical guidance in documenting the history and physical examination (H&P) of a suicidal patient. As a forensic psychiatrist, I have seen reports that fail to convey the rigor, time, and thoughtfulness that went into the work because, although lengthy, the content was not prioritized. The result is an adverse judgment, settlement, or the immense frustration of a lawsuit that could have been avoided with different (and more focused) documentation.

This article is not about how to perform a suicide assessment; it is assumed the clinician is already able to do this, or knows where to go for assistance. This article is about documentation and prioritizing the information contained in the report.

During the patient interview, the clinician will learn far more than he or she can include in the report; how do you decide what is important for posterity? It is unreasonable and disingenuous to assume that every H&P will be a thorough and rigorous journalistic recording of the facts, events, and thought processes that occurred during the interview. Should two thirds of the H&P be devoted to symptomatology—assessing for depression and the like—and one third to the assessment and plan? In addition, within any section, what needs to be written explicitly and what can be left out? In this article I offer 9 maxims to help focus the writing, using the model of an emergency department (ED) setting to illustrate. See the Table for key points addressed here.

TABLE
Key points of documenting a suicide assessment
   
  • Conducting an assessment and writing a report are 2 different processes.
  • Do not force the reader to make inferences; explain what the facts mean to you.
  • The point of a report is to communicate your clinical judgment; it should be an explicit description of how the facts of the case led you to your assessment; eg, “Based on this, I concluded that. . . .”
  • Your assessment should be so detailed and clear that your plan seems to logically flow from it.
  • Suicide risk assessment should be an evaluation of the pertinent negatives and positives and an analysis of the known risk factors; to the extent possible, you should document your thinking on these factors.
  • Use direct patient quotes whenever possible and applicable.
  • Your interventions, including the interview itself, will change how a patient feels; make a point of explaining your immediate interventions: what you did, why you did it, and the result.
  • Address why you did not use certain interventions, especially hospitalization, medications, or contacts; it may be very reasonable not to—simply explain why.

Write so the reader does not have to guess what you were thinking

The biggest mistake in medical note writing is spending too much time or using too many words in the "objective" section and not enough in the "assessment" section.

Who is going to read this report? Perhaps insurance companies will read the objective section and use it to bill accordingly. But other doctors, lawyers, and jurors will care about the assessment and plan sections. Certainly, objective facts are important to list, but the strength of the report comes from explicitly describing your thought process while drawing conclusions about the patient. You must write your assessment and plan in a way that makes it completely obvious to others why you did what you did.

A common, and I believe mistaken, approach is to force the reader to infer that the patient was not suicidal by simply listing specific behaviors, actions, or statements in the objective portion without interpreting these behaviors in the assessment section. Consider the following objective: "Patient denied suicidal ideations . . . was joking with staff . . . contracts for safety. . . ."

The problem with this listing of the facts is that the clinician is forcing the reader to connect the dots. Instead, make it obvious what you were thinking. "I was able to conclude that the patient wasn't suicidal because not only was he denying suicidality but his good affect and joking with staff reinforced that he felt better."
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