Suicide Attempt ICD-10: A Guide for Therapists on Proper Documentation and Diagnosis
Mar 4, 2025
Suicide ideation affects nearly 12.2 million American adults each year. About 1.2 million people attempt suicide, which makes accurate ICD-10 documentation a vital part of healthcare. The condition ranks as the 12th leading cause of death in the United States. Healthcare professionals and therapists just need to pay precise attention to proper coding and documentation of suicide attempts.
The current data reveals major coding accuracy problems. ICD-10 codes detect only 36.9% of hospitalized suicide attempts. The positive predictive value for intentional self-harm codes ranges from 89.8% to 97.3%. Yet many cases remain undetected in administrative data. This piece helps you tackle these documentation challenges. You'll find the most important information about proper coding, risk assessment documentation and follow-up care requirements for suicide attempts.
Understanding ICD-10 Codes for Suicide Attempts
The medical world saw a major change in October 2015 with the switch from ICD-9 to ICD-10 coding system for documenting suicide attempts and self-harm cases. Medical professionals need to understand these codes to maintain accurate medical records and get proper insurance reimbursement.
Simple structure of suicide attempt codes
Medical staff must pay special attention to T14.91, the main code for suicide attempts. The code needs a seventh character - 'A' for the original encounter, 'D' for subsequent encounter, or 'S' for sequela [1].
The ICD-10 system has detailed codes for different methods of intentional self-harm. These codes include:
Intentional self-harm by drowning (X71.0XXA - X71.9XXA)
Self-harm through firearms (X72.XXXA - X74.9XXA)
Self-harm with sharp objects (X78.0XXA - X78.9XXA)
Self-harm through other specified means (X83.0XXA - X83.8XXA) [2]
Code R45.88 helps separate self-harm without suicidal intent from self-harm with suicidal intent. Code Z91.5 now has subcategories that separate history of suicidal behavior (Z91.51) from history of other self-harm (Z91.52) [1].
Key differences from ICD-9 codes
ICD-10 brought substantial changes to coding methodology. ICD-9-CM documented self-harm using extra cause-of-injury diagnoses from E950-E958 for definitely self-inflicted injuries, and E980-E988 for unclear intent cases [3].
The system changed in several ways:
Intent became part of primary codes for poisonings and certain injuries, which removed the need for separate cause-of-injury codes [4]
Injury and poisoning categories needed more detailed specifications [4]
The new suicide attempt code T14.91 appeared, which didn't exist in ICD-9 [5]
These updates led to fewer injuries coded as undetermined intent and more self-harm coding [4]. The language also changed from "suicide and self-inflicted injury" in ICD-9-CM to "intentional self-harm" in ICD-10-CM [6].
Common coding errors to avoid
Medical coders face several challenges to maintain accuracy. T14.91, the suicide attempt code, should only appear when the nature, body region, and mechanism of injury remain unknown [6]. Records show that 6-8% of cases wrongly combine T14.91 with other specific intentional self-harm codes [6].
Data shows serious underreporting issues. ICD-10 codes catch only 36.9% of hospitalized suicide attempts [7]. Adding undetermined intent codes (Y10-Y34) slightly raises sensitivity to 41.0% [7].
Medical staff can improve coding accuracy by:
Using specific injury mechanism codes instead of defaulting to T14.91
Not mixing T14.91 with other intentional self-harm codes
Adding the right seventh characters (A, D, or S) to T14.91 codes
Using proper codes to separate self-harm with and without suicidal intent
The system makes it hard to tell the difference between self-harm with lethal intent (suicide attempt) and non-lethal self-harm [3]. Research reveals that hospital discharge records miss at least 75% of suicide attempts in emergency departments when they rely only on ICD-10 codes [7].
Essential Documentation Requirements
Documentation is the life-blood of effective suicide risk management that serves both clinical and legal purposes. Healthcare visits within one month of death occur in half of the individuals who die by suicide [8]. This makes detailed documentation crucial to identify and support at-risk patients.
Patient history documentation
Patient history records must include complete information about previous suicide attempts. These attempts remain the strongest predictor of future attempts [5]. Your documentation should cover:
Previous suicide attempts and self-harm incidents, with methods and estimated dates
Family's suicide history
Current psychiatric diagnoses and comorbid conditions
Recent major life changes or stressors
Substance use patterns and history
34% of individuals progress from suicidal thoughts to creating a plan, and 72% move from planning to attempting suicide [9]. Detailed chronological records of symptom progression help track risk escalation.
Risk assessment records
Risk assessment documentation demands precise detail. Research shows clinician assessment alone works only slightly better than chance in predicting suicide attempts. The externally validated area under the receiver operating characteristic curve reaches 0.67 for one-month predictions [8].
Your risk assessment documentation must include:
Current Risk Factors
Immediate triggers and stressors
Access to lethal means
Current suicidal ideation patterns
Thought intensity and frequency
Specific plans or preparations
Protective Factors
Social support systems
Coping mechanisms
Treatment engagement
Future-oriented planning
Patient self-reports combined with electronic health records substantially improve prediction accuracy. This achieves an AUC of 0.77 for one-month predictions [8]. So your documentation should capture both objective observations and patient-reported experiences.
Treatment plan documentation
Treatment plans serve as care roadmaps and legal records of your clinical reasoning. Your several years old guidelines require treatment plan documentation to detail [10]:
Summary of presenting complaints and current risk factors
Names of evaluation participants
Treatment options discussed with the patient
Rationale for chosen interventions
Safety planning components
Follow-up arrangements
Safety planning documentation should include:
Triggers that lead to hopelessness
Proven coping strategies practiced in sessions
Environmental safety measures
Support system's contact information
Crisis response protocols
60% of planned suicide attempts happen within the first year of ideation onset [9]. Your documentation should specify timelines for monitoring and reassessment. Clear documentation must cover:
Planned follow-up visit frequency
Missed appointment protocols
Communication channels with other healthcare providers
Criteria to modify treatment intensity
Your records must show the clinical reasoning behind assessment decisions and treatment choices [10]. 90% of unplanned attempts occur within ideation onset's first year [9]. This requires your records to demonstrate ongoing alertness and risk monitoring strategies.
Note that complete documentation serves multiple purposes beyond clinical care. 40% of college students who reported suicide attempts on single-item surveys had not actually attempted suicide based on detailed assessments later [9]. Detailed records help verify risk assessments and support accurate diagnosis and treatment planning.
Differential Diagnosis Documentation
The right way to tell different types of self-harm behaviors apart remains crucial for proper ICD-10 documentation. Research shows how the difference between suicidal and non-suicidal behaviors affects treatment approaches and patient outcomes.
Depression with suicide attempt
Clinical data shows that 95% of suicide attempts happen during major depressive episodes [11]. Patients diagnosed with depressive disorders and substance abuse disorders face about 20 times higher risk of attempting suicide [12]. While suicidal thoughts associate strongly with depression severity, many severely depressed patients show no suicidal thoughts before trying to take their life [12].
Doctors must document these key elements for depression-related suicide attempts:
Severity and duration of depressive symptoms
Substance use disorders
History of previous attempts
Current treatment status
Studies show that almost 60% of patients who attempted suicide during major depressive episodes weren't getting depression treatment at the time [12]. This highlights why we need detailed documentation to spot gaps in treatment.
Non-suicidal self-harm
Non-suicidal self-injury (NSSI) is different from suicide attempts in several ways. Research shows NSSI affects about 15-20% of adolescents and young adults, usually starting around age 13-14 [3]. Adult NSSI rates stay around 6% [3].
These features set NSSI apart from suicide attempts:
Intent and Purpose: NSSI means hurting yourself without wanting to die, mainly to handle emotions [3]
Method Selection: NSSI usually involves cutting, burning, or scratching, unlike suicide attempts that use more lethal methods [3]
Frequency Pattern: People use NSSI more often as a way to cope, while suicide attempts happen less frequently [13]
Damage Severity: NSSI usually causes surface wounds, unlike suicide attempts that lead to more serious injuries [13]
Despite these differences, research shows NSSI serves as one of the most important risk factors for future suicide attempts [3]. Studies reveal that people with NSSI history show stronger links to suicide attempts than other known risk factors, even more than previous suicide attempts [3].
Accidental self-injury
Telling accidental self-injury from intentional self-harm needs careful documentation of circumstances and intent. Research shows about 33% of people who reported self-injury needed medical care, but only 6.5% got treatment for their wounds [14].
Documentation must clearly show:
How the injury happened
Patient's mental state during the whole ordeal
Whether suicidal thoughts were present
Environmental factors that led to the accident
Studies show most people who hurt themselves do it privately to ease intense negative emotions, not to get attention [3]. This finding goes against common myths about attention-seeking behavior.
To get a full picture of differential diagnosis documentation, 69-83% of adolescents and young adults with NSSI disorder say they've tried suicide [15]. About 20% of community adolescents who meet NSSI disorder criteria said at least one of their self-injuries in the past year was actually a suicide attempt [15].
Documentation should reflect that while NSSI and suicide attempts are separate behaviors, they often happen together. Research shows people who do both typically show worse symptoms of psychopathology and have more trouble functioning compared to those who only do NSSI [16].
Risk Assessment Documentation Guidelines
A complete risk assessment document is the foundation of suicide prevention strategies that work. Studies show that approximately 2% of individuals who attempt suicide die within a year of their attempt [5]. This fact highlights why we need full risk documentation.
Immediate risk factors
Recent research points to several high-priority immediate risk factors that need detailed documentation. A standardized risk assessment should capture:
Mental State Indicators:
Signs of hopelessness about current and future circumstances - a strong predictor of suicidal behavior [5]
Current ideation patterns, including frequency and intensity
Command auditory hallucinations or psychotic symptoms
Substance use status, since alcohol misuse increases suicide risk tenfold [17]
Recent Life Events: Studies show adverse life events in the previous month make suicide risk 10.4 times higher [4]. Key documentation elements should cover:
Relationship conflicts (OR=5.0)
Legal problems (OR=4.8)
Family-related conflicts (OR=4.5) [4]
Clinical Presentation: Research shows 71.1% of suicide cases had an active mental disorder when they died [4]. Your documentation needs to detail:
Current psychiatric diagnoses
Physical health conditions, especially newly diagnosed problems
Pain levels and management strategies
Sleep patterns, especially severe insomnia
Historical risk factors
Long-term risk factors have substantial predictive value. Data shows social isolation (OR=4.0), unemployment (OR=3.8), and low socioeconomic status (OR=2.8) substantially influence suicide risk [4]. Your documentation should address:
Clinical History: Research points to several critical historical factors:
Previous suicide attempts (OR=8.5)
History of self-harm (OR=10.1)
Mental health diagnoses, particularly:
Depression (OR=11.0)
Borderline personality disorder (OR=9.0)
Schizophrenia spectrum disorders (OR=7.8) [4]
Family Background: Studies emphasize documenting:
Family's history of mental disorders (OR=5.2)
Family's history of suicide (OR=3.7)
History of childhood abuse or trauma [4]
Medical Conditions: Some physical conditions relate to increased suicide risk. You should document:
Central nervous system disorders
Autoimmune diseases
Chronic pain syndromes
Traumatic brain injuries, which can cause:
Impaired attention and concentration
Reduced processing speed
Communication difficulties
Increased impulsivity [5]
The best risk documentation uses standardized assessment tools to guide clinical interviews [7]. Your records should reflect:
Collateral information from mental and physical health records
Legal and custodial documentation when applicable
Comments from referral sources
Specific follow-up recommendations based on identified risk factors
Note that risk status changes faster than expected. Documentation should indicate high changeability when present, especially with factors like:
Impulsivity
Substance use likelihood
Current intoxication status
Level of participation
Pending legal matters
Child custody disputes [18]
In the end, your risk assessment documentation works as both a clinical tool and legal record. Studies show combining standardized assessments with clinical judgment makes predictions more accurate [18]. You should maintain detailed records of:
Risk level determinations
Clinical reasoning behind assessment conclusions
Specific interventions chosen
Monitoring frequency decisions
Re-assessment scheduling
Safety Planning Documentation
A well-laid-out safety plan plays a key role in managing suicide risk. Research suggests that patients with better quality safety plans end up in the hospital less often in the next year [19]. Clear documentation of these safety measures helps provide better patient care.
Crisis response plan
Safety planning documentation needs to spell out specific ways to handle a crisis. Your records should include:
Warning Signs Recognition:
Behaviors that come before a crisis
Thought patterns that signal higher risk
Physical signs of distress
Things in the environment that trigger crisis [20]
Internal Coping Mechanisms: List self-management techniques patients can use on their own. These include relaxation methods, physical activities, and other tailored strategies that clinical experience shows work well [2].
Crisis Resources: We need to document all emergency contacts:
Mental health professionals' contact details
Crisis hotline numbers
Local urgent care locations
Emergency department addresses [6]
Support system details
Research shows that active support from friends or family is one of the strongest shields against suicide [2]. Your documentation should capture:
Primary Support Network:
Names and contact details of trusted people
Each support person's specific role
When each contact is available
Best ways to reach them
Environmental Safety Measures: Document how support people should:
Block access to lethal items
Keep medications and sharp objects secure
Watch substance use
Stay with the person during crisis periods [2]
Social Settings: Document these details:
Safe places that offer distraction
Community resources
Where support groups meet
Religious or spiritual connections [21]
Follow-up care arrangements
Studies show quick follow-up care affects patient outcomes. Here's what follow-up documentation should include:
Immediate Post-Crisis Care:
Check-ins scheduled 2-3 days after first contact
Confirmation that home services started
Verification that medical equipment arrived [22]
Treatment Coordination: List:
Names of every healthcare provider involved
How care team members should communicate
What each provider needs to do
When to change treatment intensity [23]
Ongoing Monitoring: Outline how to:
Schedule regular risk checks
Evaluate treatment progress
Manage medications
Review if crisis plans work [6]
Documentation Updates: Create clear steps to:
Review safety plans regularly
Make changes based on patient feedback
Keep contact information current
Track support system availability [19]
Safety planning documentation should show teamwork between clinician and patient, using proven strategies to reduce suicide risk [19]. Research shows that using standard assessment tools alongside personalized safety planning leads to better outcomes [6].
Note that you should document how patients react to proposed safety measures and how likely they are to follow the plan [6]. On top of that, keep records of plan reviews, talks about what's working, and any updates needed when circumstances change or barriers come up [6].
Follow-up Documentation Requirements
Regular monitoring and documentation after a suicide attempt helps prevent future incidents. Research shows suicide risk peaks during the days and weeks right after discharge from acute care settings [1].
Ongoing risk assessment
Post-attempt documentation needs careful attention to risk levels that can change quickly. Clinical data shows suicide risk varies over time. Vulnerability increases when stressful events occur [1]. Your ongoing assessment records must include:
Risk Level Documentation:
Current risk status (low, intermediate, or high)
Factors that influence risk classification
Changes from original assessment
Why you determined the risk level
High-risk patients need more frequent monitoring with reassessment within 24 hours [24]. Moderate-risk cases need evaluation within seven days. Monthly assessments work if you have mild but current risk [24].
Environmental Changes: Your documentation should track changes in:
Living situation
Support system availability
Access to lethal means
Employment status
Legal circumstances
Research confirms using standardized assessment tools with clinical judgment makes prediction more accurate [5]. Your follow-up records should use both objective measures and clinical observations.
Treatment progress notes
Progress documentation helps track treatment effectiveness and ensures care continuity. Studies show 8-10% of previous attempters die by suicide [5]. This makes thorough progress monitoring vital.
Clinical Response Documentation: Progress notes should cover:
Changes in suicidal ideation patterns
Response to prescribed interventions
Medication compliance and effects
Therapy involvement level
Development of coping strategies
Research shows psychiatric co-morbidity raises suicide risk by a lot [5]. Progress notes must track symptoms across all diagnosed conditions. Key areas include:
Depressive symptoms
Anxiety levels
Substance use patterns
Sleep disturbances
Pain management
Treatment Adherence Records: Your documentation needs to show:
Scheduled appointment attendance
Completion of therapeutic tasks
Use of support services
Safety plan implementation
Medication compliance patterns
Studies highlight that all but one of these initial mental health appointments go uncompleted during high-risk periods [25]. Your documentation must outline specific ways to handle missed appointments and treatment non-adherence.
Collaborative Care Updates: Progress notes should capture communication with:
Primary care providers
Psychiatrists
Social workers
Family members
Support system contacts
Research shows patients with traumatic brain injuries might have cognitive issues that affect their suicide risk [5]. Progress notes for these patients must also track:
Changes in attention and concentration
Processing speed variations
Communication abilities
Problem-solving capabilities
Judgment capacity
Documentation serves both clinical and legal purposes [1]. Your records must show why you made clinical decisions and document all consultations with supervisors or experienced colleagues [26]. Keep detailed accounts of treatment plan changes, including:
Changes in intervention strategies
Updates to monitoring frequency
Safety planning revisions
Medication regimen adjustments
Changes in support system involvement
Insurance and Billing Considerations
Insurance coverage for suicide attempts needs careful attention to documentation and billing practices. HIPAA federal regulations stop employment-based health plans from discriminating against people based on specific medical conditions [27].
Required documentation elements
Your documentation must establish clear links between suicide attempts and mental health conditions to process insurance claims. Studies show that all but one of these people who die by suicide have a mental health condition [27]. Your records should detail:
Mental Health Documentation:
Main psychiatric diagnoses
Treatment history
Current medication regimens
Risk assessment outcomes
Medical Necessity Elements:
Physical injury severity
Required interventions
Expected recovery timeline
Functional impairment levels
Insurance claims get denied because doctors don't link suicide attempts to diagnosed conditions well enough. Federal regulations mandate coverage when such conditions become apparent, even without prior diagnosis [27].
Billing Code Requirements:
CPT code 96127 to assess emotional/behavioral health
ICD-10 codes that match specific injuries
Assessment results and scoring
Up to four screeners per patient visit [8]
Common reimbursement issues
Several challenges exist in getting insurance coverage for suicide-related care. Data reveals health plans still refuse coverage for suicide-related medical costs, despite federal law prohibitions [27].
Source-of-injury Exclusions: Insurance companies could deny coverage based on "source-of-injury" exclusions in the past. These exclusions can't apply now if injuries stem from mental health conditions [27]. Some plans still try to implement restrictions through:
Policy language that excludes "intentionally self-inflicted" injuries
Clauses that deny coverage whatever the mental state
Limits on specific treatment types
Coverage Gaps: Research shows these common reimbursement challenges:
Alternative coverage plans often exclude suicide-related services [9]
Marketplace plans might have suicide exclusion clauses [27]
High deductibles and copays create big financial barriers [9]
Balance Billing Concerns: Emergency care outside the network leads to balance billing problems. To cite an instance, see a case study where a USD 6,600 hospital charge was denied, and the patient had to negotiate a payment plan [27].
Parity Law Considerations: Mental health parity laws require plans to provide similar coverage for mental health and medical/surgical benefits [27]. In spite of that, denials after suicide attempts usually involve medical/surgical claims rather than mental health services, which creates coverage complexities [28].
Appeal Procedures: Take these steps when facing claim denials:
Ask to resubmit with updated diagnosis information
File appeals with health plans
Submit complaints to state insurance divisions
Get external independent reviews [9]
Court cases about benefit denials usually favor coverage when suicide attempts link to diagnosed conditions [27]. Studies also show that using standardized assessments with detailed documentation substantially improves reimbursement success rates [29].
The best reimbursement outcomes need complete records that show:
Clear links between attempts and underlying conditions
Medical necessity for all interventions
Treatment guideline compliance
Regular monitoring and assessment procedures
Note that insurance coverage patterns change in different states and individual plans [27]. Therefore, learn about specific plan requirements and state regulations that govern mental health coverage. On top of that, it helps to record all communication with insurance providers, including dates, times, and names of representatives contacted.
Quality Assurance Measures
Quality assurance measures serve as the life-blood of maintaining high standards in suicide attempt documentation and care. Good quality control processes will give a complete picture of ICD-10 coding, risk assessments, and suicide prevention best practices.
Documentation review process
Quality assurance in suicide attempt care needs a systematic documentation review process. Studies show that discharge summaries with insensitive wording or graphic details can make patients feel ashamed and increase stigma [10]. Healthcare facilities should set up a review protocol that covers:
Discharge Summary Audits: Regular audits of discharge summaries help review suicide attempt documentation quality. A simple change reduced stigmatizing phrases like "commit suicide" by a lot (OR 0.279; CI 0.0921 to 0.8452, p = 0.0240) [10]. Staff should check:
Sensitive language guidelines compliance
ICD-10 codes accuracy for suicide attempts
Risk assessment documentation completeness
Follow-up care instructions clarity
Electronic Health Record (EHR) Integration: EHR systems can make the documentation review process quicker. Patient self-reports combined with electronic health records improve suicide risk prediction accuracy, reaching an AUC of 0.77 for one-month predictions [10]. The EHR should:
Alert staff about inappropriate language or coding
Guide clinicians through essential documentation
Create quality assurance review reports
Peer Review Mechanisms: Clinicians should review each other's documentation through a peer review system. This helps improve documentation quality and creates learning opportunities. The system should include:
Anonymous feedback channels
Case conferences for complex documentation scenarios
Experienced clinicians mentoring newer staff
Continuous Education: Staff need ongoing training about documentation best practices. Research shows better patient care and less iatrogenic harm when clinicians understand documentation issues and sensitive language [10]. Training should cover:
Latest ICD-10 coding for suicide attempts
Risk assessment documentation methods
Safety planning requirements
Cultural awareness in suicide-related notes
Compliance checklist
A complete compliance checklist helps keep suicide attempt documentation consistent among healthcare providers. Standard assessment tools with clinical judgment give better prediction accuracy [10]. The checklist should include:
ICD-10 Coding Accuracy: Staff must use correct suicide attempt ICD-10 codes:
T14.91 for suicide attempts
X71-X83 for specific self-harm methods
Z91.5 for self-harm history
Risk Assessment Documentation: Essential risk assessment elements include:
Current suicidal thoughts
Past suicide attempts
Access to lethal means
Protective factors
Mental health diagnoses
Safety Planning Components: A complete safety plan should document:
Triggers and warning signs
Personal coping methods
Support resources
Means restriction steps
Emergency contacts
Follow-up Care Arrangements: Post-discharge care plans need:
Follow-up appointment schedules
Mental health specialist referrals
Medication instructions
Crisis response steps
Legal and Ethical Considerations: Documentation must meet legal and ethical standards:
Informed consent records
Confidentiality measures
Involuntary hospitalization procedures when needed
A scoring system can help measure compliance checklist effectiveness. One study created a 10-item emergency department checklist and a 16-item risk assessment list [30]. This helps measure documentation quality and find areas that need work.
Quality Improvement Initiatives: Compliance checklist data should drive improvements:
Find common documentation gaps
Create focused training programs
Make system-wide changes for recurring issues
Set documentation quality goals
A dedicated quality assurance committee should oversee suicide attempt documentation. This committee can:
Track compliance patterns
Fix documentation system issues
Update documentation guidelines
Work with IT to improve EHR features
Note that quality assurance in suicide attempt documentation affects patient care and outcomes directly. Studies prove that good documentation leads to better treatment plans and fewer future attempts [10]. The clinical value of thorough documentation should be emphasized in all quality efforts.
These quality assurance measures can improve suicide attempt documentation's accuracy, completeness, and sensitivity. Better documentation supports more effective care and leads to improved outcomes for suicide risk patients.
Conclusion
Accurate documentation of suicide attempts through ICD-10 codes builds the foundation to deliver effective patient care and treatment outcomes. Current data reveals major challenges in precise coding. Your deep understanding of documentation requirements will lead to improved patient care and risk management.
Documentation goes beyond basic paperwork - call it a vital tool that prevents future attempts and supports patient recovery. Precise risk assessment records, safety planning, and follow-up care arrangements boost treatment effectiveness and patient outcomes by a lot.
Your dedication to keeping detailed records, from differential diagnosis documentation to insurance needs, directly affects patient safety and care quality. A combination of standardized assessment tools and clinical judgment offers the most reliable way to evaluate risks and plan treatments.
Becoming skilled at suicide attempt documentation needs ongoing education and quality checks. When you consistently apply these documentation principles and guidelines, you'll build medical records that drive both immediate care and long-term treatment success.
FAQs
What is the primary ICD-10 code for documenting a suicide attempt?
The primary ICD-10 code for documenting a suicide attempt is T14.91. This code should be used when the nature, body region, and mechanism of injury are unknown. It's important to include the appropriate seventh character (A, D, or S) to indicate the encounter type.
How should therapists differentiate between suicide attempts and non-suicidal self-harm in their documentation?
Therapists should document the intent behind the self-harm. Suicide attempts involve deliberate self-harm with the intention to end one's life, while non-suicidal self-injury (NSSI) is typically used as an emotional regulation mechanism without suicidal intent. Documentation should include the method, frequency, and severity of self-harm, as well as the patient's reported motivation.
What are the essential elements of a comprehensive risk assessment for suicide?
A comprehensive risk assessment should document current risk factors (such as immediate triggers, access to lethal means, and suicidal ideation patterns), protective factors (like social support and coping mechanisms), and historical risk factors (including previous attempts, mental health diagnoses, and family history). It should also include the clinician's assessment of overall risk level and rationale for this determination.
How often should follow-up assessments be conducted and documented after a suicide attempt?
Follow-up assessment frequency depends on the patient's risk level. High-risk patients should be reassessed within 24 hours, moderate-risk cases within seven days, and mild-risk cases monthly. Documentation should reflect these reassessments, noting any changes in risk factors, treatment response, and overall risk level.
What key elements should be included in safety planning documentation?
Safety planning documentation should include identified warning signs, internal coping strategies, external support resources, means restriction measures, and emergency contact information. It should also detail the crisis response plan, support system involvement, and follow-up care arrangements. Regular reviews and updates to the safety plan should be documented as well.
References
[1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC3146379/
[2] - https://sprc.org/wp-content/uploads/2022/11/Section-4-Patient-Management-Tools.pdf
[3] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4244874/
[4] - https://pmc.ncbi.nlm.nih.gov/articles/PMC9685708/
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[6] - https://www.mentalhealth.va.gov/mentalhealth/docs/va_safety_planning_manual.doc
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[8] - https://health.maryland.gov/pdmp/Documents/Billing for Suicide Risk Assessment.pdf
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[10] - https://www.researchgate.net/publication/384603014_An_Audit_on_Sensitive_Documentation_of_Suicide_Attempts_and_Behaviour_in_Mount_Carmel_Hospital_Discharge_Summaries
[11] - https://www.sciencedirect.com/science/article/abs/pii/S016517811931371X
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[14] - https://www.selfinjury.bctr.cornell.edu/about-self-injury.html
[15] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4584484/
[16] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8232570/
[17] - https://www.preventsuicideny.org/risk-factors-associated-with-suicide/
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[19] - https://zerosuicide.edc.org/toolkit/evidence-base/engage
[20] - https://www.healthquality.va.gov/guidelines/MH/srb/PHCoECrisisResponsePlanCSTVersion2SelfPrint3112020FINAL508Report.pdf
[21] - https://ictp.uw.edu/wp-content/uploads/2024/03/Suicide-risk-assessment-and-documentation-8-3-23.pdf
[22] - https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
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