Commentary: Think fast, act quickly, and document (maybe).

The article by Elbogen et al. makes a valuable contribution to the little-studied connection between documentation of violence risk information and risk management. Some clinicians neither take the time nor have the inclination to document violence risk assessments adequately. When the clinician is confronted with a patient at imminent risk of becoming violent toward others or himself, the clinical focus is on rapid intervention. Documentation of the clinician’s risk assessment rationale is often an afterthought, if it is done at all. It is my experience that even unhurried clinicians rarely document evidence of violence adequately in their risk assessments and clinical decision-making. However, asking busy, harried clinicians in today’s managed-care environment to complete time-consuming risk assessment protocols is a fool’s errand. The authors cite the work of Malone et al. regarding the documentation of suicide risk assessments. This provides an opportunity to discuss the parallel topic of documenting the assessment and management of patients at risk for suicide. Malone et al. studied clinicians, including psychiatrists, who performed routine intake and discharge assessments of 50 patients identified by systematic research evaluations as having attempted suicide and as having a current major depressive episode. They found that the clinicians failed to document adequately the presence of a lifetime history of suicide attempts in 24 percent of cases at admission and in 28 percent of cases in the discharge summary. In 38 percent of the patients, the physician’s discharge summary did not document the presence of recent suicidal ideation or planning behavior. The authors conclude that a significant degree of past suicidal behavior is not recorded during routine clinical assessment. They recommend the use of semistructured screening instruments to improve documentation and to detect lifetime suicidal behavior. For outpatient clinicians responsible for follow-up, adequate documentation identifies the high-risk population at time of discharge. The study underscores the importance of systematic suicide risk assessment. Documentation is an essential part of patient care. It encourages the practitioner to sharpen clinical focus and clarify decision-making rationale. The record comes alive as an active clinical tool, not just an inert document. The clinician treats the patient, not the chart. Documentation as a risk management tool supports good clinical care. When patients are at risk of suicide, it is necessary to document all interventions as well as the rationale for such actions. Documentation should contain answers to the following basic questions: what was done, the reason(s) for doing it, and the rationale for rejecting alternative interventions or treatments. Suicide risk assessments should be recorded when performed. Psychiatrists who do adequate suicide risk assessments may not always record them. Suicide risk assessment and documentation in outpatient settings are usually performed during the initial interview, at the emergence of suicidal ideation or behavior, and when a significant change occurs in the patient’s condition. In inpatient facilities, important points of documentation of suicide risk assessment occur at admission, changes in supervision level, ward changes, the issuance of passes, marked changes in the patient’s clinical condition, Dr. Simon is Clinical Professor of Psychiatry and Director, Program in Psychiatry and Law, Georgetown University School of Medicine, Washington, DC. Portions of this Commentary have been adapted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinical Risk Management. Washington, DC: American Psychiatric Publishing, Inc., in press. Address correspondence to: Dr. Robert I. Simon, 7921-D Glenbrook Road, Bethesda, MD 20814. E-mail: risimonmd@aol.com