Suicide/Self-Harm Risk Assessment & Safety Plan Note

Date/Time of Assessment: [Date and time]

Setting: [ED / inpatient unit / clinic / telehealth / mobile crisis / other]

Reason for Assessment: [Brief referral context such as positive suicide screen, self-harm event, family concern, patient-initiated request]

Sources and Reliability: [Data sources: patient interview / collateral contacts / chart review / EMS / other] [Reliability qualifiers if applicable: intoxication / guardedness / language barrier / cognitive impairment / other] (Name all sources used. Note any factors that limit assessment reliability.)

Immediate Safety Status

(Include this section when there is current suicidal ideation, a recent attempt, uncertain reliability, or concern for imminent risk. Otherwise omit.)

• Current suicidal thoughts right now: [yes / no / unable to assess]
• Current safety precautions in place: [Observation level / belongings search / environmental precautions / who is present / other]
• If self-harm or attempt occurred: [Injury description, treatment provided, medical clearance status]

Presenting Problem

[Why the patient is presenting today] (Open with the precipitating concern prompting assessment.)

[Precipitating events, stressors, timeline, course of symptoms, and the patient's articulated meaning or function of suicidal thoughts or self-harm] (Write 1–2 concise narrative paragraphs. Use neutral, behaviorally specific language. Include direct patient quotes for high-risk statements.)

Suicide and Self-Harm Inquiry

(Document structured assessment. For any domain not assessed, document "Not assessed" with reason and plan to reassess if indicated.)

Suicidal Ideation

• Presence: [yes / no / unable to assess]
• Type: [passive death wish / active suicidal ideation]
• Timeframe: [past 48 hours / past month / lifetime worst]
• Frequency: [Description]
• Intensity: [Description]
• Duration: [Description]
• Controllability: [able to resist / requires effort / unable to resist / unknown]

Plan

• Presence of plan: [yes / no / unable to assess]
• Method(s): [Description]
• Specificity: [Timing, location, detailed steps]
• Perceived lethality: [low / moderate / high] (Patient's perception)
• Feasibility and access: [Description]
• Preparatory acts: [acquired means / researched methods / wrote notes / rehearsed / none]

Intent

• Intent to act: [yes / no / ambivalent / unable to assess]
• Likelihood of acting: [not at all / somewhat / likely / imminently / unable to assess]
• Perceived lethality if acted upon: [low / moderate / high / unknown]
• Reasons to die vs. reasons to live: [Brief, balanced summary] (Include direct quotes for high-risk statements.)

Suicidal Behaviors

• Most recent actual attempt: [Date, method, medical severity, rescue circumstances, intoxication status, stated intent at time]
• Most medically severe past attempt: [Date, method, medical severity, rescue circumstances, intoxication status, stated intent at time]
• Interrupted attempts: [Description / none]
• Aborted attempts: [Description / none]
• Preparatory behaviors: [Description / none]
• Pattern: [impulsive / planned / intoxication-related / mixed]

Non-Suicidal Self-Injury

• Presence: [yes / no / unable to assess]
• Behaviors: [cutting / burning / hitting / scratching / other]
• Frequency and recency: [Description]
• Triggers and function: [emotional regulation / self-punishment / interpersonal / sensory / other]
• Medical severity: [Description] (Clearly distinguish NSSI from suicidal behavior.)

Access to Lethal Means

• Firearms: [Presence, type, storage, who controls access]
• Medications: [High-risk medications present, quantities, stockpiles]
• Other means: [Ligatures / heights / sharp objects / chemicals / other]
• Means-safety counseling provided: [yes / no] [Summary of counseling content]
• Specific safety actions: [What will be secured, who will do it, by when, verification status]
• If patient declines means-safety: [Interventions offered, patient's reason for declining, alternative mitigations] (Include only if applicable.)

Risk and Protective Factors

Acute/Dynamic Risk Factors

[Escalating ideation, plan, intent, recent attempt, agitation, insomnia, intoxication/withdrawal, psychosis, severe hopelessness, recent discharge, loss of supports, increased access to means]

Historical/Static Risk Factors

[Prior attempts, psychiatric diagnoses, childhood adversity, trauma history, family history of suicide, chronic pain, medical comorbidity]

Protective Factors

• Internal: [Reasons for living, coping skills, future orientation, religious/moral beliefs]
• External: [Supportive relationships, dependents, treatment engagement, restricted access to means]

(Comment on the current reliability and availability of each protective factor.)

Clinical Context

• Psychiatric diagnoses and current symptoms: [Brief summary relevant to risk]
• Substance use: [Pattern, recent use, relation to suicidality, withdrawal risk]
• Pertinent medical factors: [Pain, sleep, pregnancy/postpartum, cognitive status, relevant medications]

Mental Status Examination

• Appearance/Behavior: [Description]
• Psychomotor: [normal / agitation / retardation]
• Speech: [Rate, volume, prosody]
• Mood and Affect: [Stated mood; affect range, congruence, stability]
• Thought Process: [linear / tangential / disorganized]
• Thought Content: [SI/plan/intent, HI, delusions, guilt, hopelessness]
• Perceptions: [Hallucinations, command content if present]
• Cognition: [Orientation, attention, memory]
• Insight and Judgment: [Description]
• Impulse Control: [intact / impaired]

Collateral and Consultation

(Include if collateral or consultation materially affects risk estimation, safety planning, or disposition. Otherwise omit.)

• Collateral contacts: [Name, relationship, key information obtained, discrepancies with patient report]
• Consultations: [Service consulted, recommendations, how incorporated]

Risk Formulation and Level

[Integrated narrative formulation synthesizing: ideation, plan, intent, and behaviors; means access and changes today; acute risk drivers; protective factors and their current reliability; patient's capacity and willingness to follow safety plan; and feasibility of treatment engagement] (Use neutral, behaviorally specific language. Include direct quotes for high-risk statements.)

• Acute/Imminent Risk Level: [none / low / moderate / high / unable to assess] — Rationale: [Specific explanation tying findings to level]
• Chronic/Baseline Risk Level: [none / low / moderate / high] — Rationale: [Specific explanation referencing history and enduring factors]
• Validated tool (if used): [Tool name, score, interpretation] (Disposition is based on clinical evaluation and context rather than score alone.)

Safety Plan

(Collaboratively completed in patient-centered language. Do not frame as a contract. If patient refuses or cannot complete, document refusal, reason, and alternative safety measures.)

• Warning signs: [Patient-identified warning signs]
• Internal coping strategies: [Things patient can do alone]
• People and places for distraction: [Names/places with contact information]
• People I can ask for help: [Names/relationships with contact information]
• Professional and crisis resources: [Clinician contact, 988 Suicide & Crisis Lifeline, local crisis services, emergency services]
• Means-safety steps agreed upon: [What will be secured, who is responsible, by when]
• Anticipated barriers and problem-solving: [Barriers identified, strategies discussed]
• Patient received copy of safety plan: [yes / no / declined]

Disposition and Follow-up

• Disposition: [discharge with safety plan / crisis stabilization / observation / voluntary psychiatric admission / involuntary hold / other] — Justification: [Tie to risk formulation, means safety, capacity to adhere, supervision feasibility]
• Legal status (if applicable): [voluntary / involuntary] — Rationale: [Brief]
• Follow-up arrangements: [Appointments scheduled, warm handoff details, care coordination]
• Monitoring/outreach: [Check-in calls/texts, caring contacts, responsible party]
• Return precautions: [When to call clinician, call 988, present to ED, call 911]
• Caregiver instructions (if applicable): [Supervision plan, means-safety responsibilities, education provided]

(Never document a risk level without supporting rationale. Do not omit high-stakes domains—ideation, plan, intent, behaviors, means access—without documenting why assessment was not possible.)