Protecting Your Patients and Yourself

Feb 2016

Zero Suicide represents a commitment to identify, protect, and treat people who are at risk of suicide. Central to this commitment is the ability to record and properly share accurate information about a patient’s history and treatment. Without this information, each clinician that treats a patient must start from scratch — an inefficiency that will frustrate health care providers and patients, as well as affect the quality of care. Careful documentation also allows us to understand how health care systems can be improved and patient care made more effective.

The documentation essential to Zero Suicide has another benefit. It can protect clinicians and institutions from malpractice suits. Suicide is the most common cause of legal action against mental health care professionals. The central issues in most suicide malpractice cases are whether the clinician should have anticipated the risk of suicide and whether he or she provided care appropriate to this risk. Showing that a clinician met the standard of care appropriate for suicide risk can stop a malpractice suit in its tracks. Patient care should be documented in real time. Juries may suspect that medical records created after the fact rather than during treatment are inaccurate or self-serving.

Assessments of suicide risk should be carefully documented. It is a fundamental principle of good practice that risk assessment is more than simply using a screening instrument—clinical observation and judgment are also essential. These observations should be documented in the patient’s medical record. Patient responses to questions about suicide and self-harm should be recorded in their own words, and quotation marks used to clearly distinguish which statements represent clinical judgments and which are verbatim reports of what a patient said.

Embarrassment and anxiety can make patients reluctant to admit they are thinking about suicide. They may want to protect family secrets about substance abuse, mental health disorders, sexual abuse, or family violence. They may be in denial or afraid of being institutionalized or feel that no one can help. Involving family members can be crucial to accurately assessing a patient’s risk and making care decisions. Family members can provide information that the patient can’t—or won’t—and this information should be carefully recorded. It should also be noted if family members cannot be reached or are uncooperative. If a suicide results in a malpractice suit, it is the family that will sue. Accurate information about the family’s involvement—or lack of involvement—in patient care can be critical to the outcome.

The clinician should also document the decisions made while developing a patient care plan, how this care plan was implemented, and the criteria used to decide the steps needed to preserve the patient’s safety (such as whether the patient admitted to actively planning his or her suicide and whether the patient has access to firearms).

It is also important for the clinician to document his or her review of medical records and consultations with other service providers. If medical records or prior providers are not available, all attempts to obtain records and reach providers should be documented.

Focusing on the possibility of malpractice lawsuits turns the clinician’s attention away from the patient to him- or herself. Thoroughly and accurately documenting the assessment and care of patients who may be at risk of suicide will help deter malpractice lawsuits as well as contribute to quality care, patient safety, and the ability of clinicians and the health care system to work toward the goal of zero suicides.

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