You may feel confident that you’ve assessed – and documented – your client’s risk of harm to themselves or others.

But it is likely that your session notes fall short in one of three common (and potentially serious) ways:

• PROBLEM #1: You screened for risk at intake, but your intake note doesn’t show how you determined that the client is not at risk.
• PROBLEM #2: Since the intake, you haven’t written anything about the client’s current risk status, something that should be in each session note.
• PROBLEM #3: You are using an Electronic Health Record (EHR) where limited checkbox choices have pushed you into inaccurate documentation. You are checking “client denies suicidal ideation” when you didn’t even ask the client directly about suicide in the session. If you didn’t ask, how could they deny it?

First: Must you chart a client’s risk status in each note?

Absolutely. If your notes go silent on risk after intake, it can look like you stopped assessing. And many health plans and licensing boards require that risk be assessed and documented in each session note. Some kind of notation about the client’s current risk status also helps protect you if a client ever files a complaint. And it might help protect you if a client’s family ever sues you if a client took their own life or hurt someone else.

I learned the hard way….

In my long career in private practice, I had one client who made a serious attempt to take her life, and one who harmed someone else. Since both were not expected, I hadn’t been overly vigilant about my session notes. But I was grateful that I had documented my risk assessment for both clients, especially because my notes were subpoenaed by the victim’s family in the one case. After that, I routinely documented all clients’ risk status in every note.

4 tips when documenting risk for ALL clients

1. Your intake note should specify how you assessed for risk, both the questions you asked and client responses to queries about past and present suicidal/homicidal ideation and substance use.
2. Every session note should include a “current risk status” line. I can’t stress this enough.
3. “Client denies suicidal ideation” should only appear in a note when you asked a direct question and the client denied it. Every session note should include a “current risk status” line. If your EHR forces this option, ask the makers of your program to change this.
4. If you didn’t ask the client directly about harm in the session, write something like “no risk factors suspected based on presentation and discussion.”

Let’s do better at assessing risk

• Let’s ask clients more frequently and directly about risk factors. This is not just a “one-and-done” task. Risk levels will change throughout treatment, with ongoing stressors/life changes, substance use, and setbacks.
• Indirect questions can also be revealing. Ask if they ever feel like giving up, or ever wish they would not wake up or could disappear off the planet.
• One of my favorite risk questions is: “You are dealing with alot – Are you coping in any ways that you know aren’t too healthy for you?”
• Assess for behaviors other than suicide. Have they felt like harming others? Are they cutting? Are they using alcohol, drugs, prescriptions or over-the-counter drugs in a way that is problematic?

Documentation for at-risk clients

If you do have a client with a risk history or current risk factors, be sure to:

• document the specific risk factors
• document protective factors: What keeps the client from acting on self-harm/harm ideas? Include supportive elements like family, treatment engagement, and religious beliefs
• document your clinical reasoning for decisions such as hospitalizing or not, and any referrals
• document client quotes when possible to capture client intent and mindset
• document the safety plan including steps, coping strategies, and emergency contacts discussed with the client, and any actions you plan to take to mitigate risk (e.g., contacting family, removing lethal means, increasing session frequency)