Safety Risk Assessment Note (Suicide/Homicide)

Date/Time: [Date]; [Start time] - [End time]

Setting: [ED / inpatient / outpatient / consult / phone / video]

Evaluator: [Evaluator name, credentials]

Reason for Assessment: [One-line trigger for today's risk assessment]

Communication Supports: [Interpreter used / collateral present with relationship / guardianship status / capacity concerns] (Omit line if none apply.)

Sources of Information

• [Patient interview, language used, interpreter if applicable]
• [Collateral contact(s): name, relationship, information obtained] (Include only if obtained.)
• [Prior records reviewed: type and date range] (Include only if reviewed.)
• [EMS/police report summary] (Include only if reviewed.)
• [Prescription monitoring program query] (Include only if reviewed.)
• Reliability: [Overall reliability assessment and limitations such as intoxication, psychosis, guardedness, language barrier, or time constraints; impact on assessment]
• [Collateral attempts unsuccessful: who was contacted, method, outcome; how this influenced safety planning] (Include only if applicable.)

Chief Concern

[Brief summary of what changed, who raised the concern, and precipitating events; direct patient quote if it clarifies intent or denial: "[Patient quote]"] (Use objective, non-stigmatizing language.)

Suicide Risk Inquiry

(Include only when suicide or self-harm concern is present.)

• Ideation: [Present / absent]; [Passive / active]; [Frequency]; [Intensity]; [Duration]; [Controllability] (Anchor to last 48 hours, past month, worst-ever if relevant.)
• Plan: [Method]; [Timing]; [Location]; [Expected lethality]; [Availability of means]; [Preparatory acts such as notes, giving away possessions, acquiring means]
• Intent: [Expectation of acting]; [Reasons to die]; [Reasons to live]; [Deterrents]
• Past suicidal behavior: [Prior attempts with approximate dates, methods, medical severity, treatment]; [Aborted or interrupted attempts]; [Non-suicidal self-injury if relevant]
• Immediate safety actions already taken: [Means removal / supervision / environment changes; who initiated and when]
• [Unable to assess / Patient declined: reason and compensatory steps taken] (Include only if applicable.)

Violence/Homicide Risk Inquiry

(Include only when violence, homicide, or threat concern is present.)

• Violent ideation: [Present / absent]; [Frequency]; [Intensity]; [Triggering context such as conflict, paranoia, command hallucinations, intoxication]
• Target and specificity: [Identified target and relationship]; [Proximity and access to target]; [Protective inhibitors such as remorse, fear of consequences]
• Plan, means, and intent: [Steps planned]; [Weapons or tools available or recently acquired]; [Stated or conditional intent]; [Escalation markers such as stalking, prior threat-to-action history]
• Prior violence: [Past assaults, domestic violence, weapons use]; [Legal involvement]; [Pattern: impulsive / planned]
• Immediate safety needs for others: [Security precautions / separation from potential victims / urgent notifications]
• [Third-party threat reports: source, verification efforts, how uncertainty influenced safety plan] (Include only if applicable.)
• [Unable to assess / Patient declined: reason and compensatory steps] (Include only if applicable.)

Relevant Background

(Include only information that materially affects today's risk formulation.)

• [Psychiatric diagnoses and current symptoms affecting risk]
• [Substance use: recent use, intoxication signs, withdrawal risk]
• [Medical factors impacting risk: pain, TBI, delirium, other]
• [Treatment history: prior hospitalizations, current medications, adherence, recent changes]
• [Acute social stressors: housing, relationship, legal, financial, occupational]
• [Protective commitments: caregiving responsibilities, community involvement, spiritual connections]

Lethal Means Assessment

(Required when suicide or violence risk is present.)

• Firearms: [Ownership by patient or household]; [Location]; [Storage: locked / unlocked, loaded / unloaded]; [Access to keys or codes]
• Medications: [Stockpiles]; [High-lethality agents]; [Supervision of dispensing]
• Other means: [Sharps]; [Ligatures]; [Toxic substances]; [Heights]; [Other specific concerns]
• Means-safety plan: [Who will secure or remove items]; [Where stored]; [Timeframe]; [Verification: collateral-confirmed / patient agreement only]
• Violence-specific access: [Access to weapons]; [Ability to reach identified targets]; [Restrictions in place] (Include only if violence risk present.)

Risk and Protective Factors

Acute/Dynamic Risk Factors (Include only those present today.)

• [Recent escalation in ideation or planning]
• [Recent attempt or violent act]
• [Intoxication or withdrawal]
• [Agitation, insomnia, severe anxiety]
• [Psychosis or command phenomena]
• [Acute losses, crisis, humiliation, or legal stressors]
• [Access to lethal means]
• [Social isolation or inability to engage supports]

Chronic/Static Risk Factors

• [History of suicide attempts or serious violence]
• [Chronic psychiatric illness or personality pathology]
• [Longstanding access to weapons or high-lethality means]
• [Early trauma, adversity, or chronic medical illness]

Protective Factors (Include only credible, currently available factors.)

• [Supportive relationships willing to assist]
• [Willingness to seek help and collaborate on safety planning]
• [Effective coping skills currently usable]
• [Reasons for living, responsibilities, future orientation]
• [Reduced access to means or secure storage]
• [Engagement with treatment or community resources]

Mental Status Examination

• Appearance/behavior: [Description, cooperation, distress level]
• Psychomotor: [Agitation / retardation / normal]
• Speech: [Rate, volume, tone]
• Mood and affect: [Stated mood]; [Affect: range, reactivity, congruence]
• Thought process: [Linear / goal-directed / tangential / disorganized]
• Thought content: [SI/HI status]; [Delusions or paranoia]; [Hopelessness or guilt]
• Perceptions: [Hallucinations]; [Command content if present]
• Cognition: [Orientation]; [Attention]; [Memory]; [Intoxication signs]
• Insight and judgment: [Level]; [Risk awareness]
• Impulse control: [Adequate / limited / poor]
• Ability to collaborate on safety planning: [Adequate / limited / unable]

Screening Instruments

(Include only if validated tool was administered.)

• [Instrument name and version]; [Administration time]; [Score]; [Interpretation]
• [Discordance between instrument result and clinical impression with explanation] (Include only if present.)

Clinical Formulation and Risk Stratification

[Integrative summary linking today's trigger, symptoms and behaviors, means access, history, supports, and reliability limitations; primary drivers of current risk; modifiable factors today; uncertainties and how managed]

• Acute Suicide Risk: [Low / Moderate / High] — [Justification with concrete facts]
• Chronic Suicide Risk: [Low / Moderate / High] — [Justification with concrete facts]
• Acute Violence Risk: [Low / Moderate / High] — [Justification with concrete facts]
• Risk to Specific Person(s): [Identified target(s) with rationale] (Include only if applicable.)

Safety Plan

(Include when any ongoing risk is present; use patient-facing language.)

• Warning signs: [Personal early indicators]
• Internal coping strategies: [Patient-identified techniques]
• Social settings and distractions: [People and places for support]
• People to ask for help: [Names and phone numbers]
• Professional resources: [Clinic contact]; [988 Suicide & Crisis Lifeline]; [911]; [Local crisis services]
• Means-safety steps: [Actions agreed upon, responsible person, timeframe, verification method]
• Barriers and solutions: [Anticipated obstacles and workarounds discussed]
• Plan storage and sharing: [Where kept; who has copy; patient received copy and reviewed for usability]
• Violence-specific strategies: [De-escalation strategies]; [Substance avoidance plan]; [Separation or no-contact plan]; [When to call 911] (Include only if violence risk present.)

Disposition and Follow-up

• Disposition: [ED transfer / voluntary admission / involuntary hold / crisis stabilization / partial hospitalization / intensive outpatient / outpatient management]
• Rationale: [Why this is the least restrictive safe option; why less restrictive alternatives not chosen]
• Observation and environmental safety: [Level: continuous / 1:1 / every 15 minutes / every 30 minutes]; [Environmental modifications] (Include only if applicable.)
• Follow-up plan: [Appointment scheduled or warm handoff completed]; [Caring contact plan within 24-48 hours]; [Explicit return precautions] (Include for non-admitted patients.)

Coordination and Notifications

(Include only when collateral contact, handoff, or notifications occurred.)

• [Collaterals contacted: name, relationship, time, information obtained, consent status]
• [Handoff to receiving clinician or team: summary given, method]
• [High-risk notifications: threat assessed, rationale for seriousness and imminence, information disclosed, recipient, how recipient can mitigate risk] (Include only if duty to warn/protect invoked.)

Patient Education and Consent

(Include only when education provided, refusals occurred, or consent documented.)

• [Risks and treatment options discussed; patient's understanding and agreement]
• [Refusals: what was refused, capacity assessment, counseling provided, alternatives offered, safety plan adjustments]
• [Consent for collateral communication obtained] (Include only if applicable.)

Signature: [Name, credentials, date/time]

Attachments: [Safety plan document / crisis resources provided] (Include only if referenced.)

(Omit sections that do not apply. Document "Unable to assess" or "Not obtained" with reason and compensatory steps when information cannot be obtained. Do not use or document "no-suicide contracts." Note should demonstrate systematic risk assessment, clinical formulation, and specific mitigation plan.)