How to Address Suicidality, Homicidality, and Other Emergencies in Progress Notes
As mental health professionals, we know that our work involves not just helping our clients heal, but also ensuring their safety. And while we hope for the best, we also need to prepare for the worst. This is why documenting risk assessment and safety planning is essential in our progress notes.
Why is this so important, you may ask? Well, for starters, it helps us keep track of our clients’ mental health status and any potential risks they may pose to themselves or others. This includes identifying and addressing suicidality, homicidality, and any other emergency situations that may arise.
In addition, documenting risk assessment and safety planning can also help us communicate effectively with other mental health professionals involved in our clients’ care. It allows for a coordinated and collaborative approach, ensuring that our clients receive the best possible care and support.
So, how can we effectively document risk assessment and safety planning in our progress notes? Here are a few tips:
Be thorough: When conducting a risk assessment, make sure to gather as much information as possible from your client. This includes any history of suicidal or homicidal ideation or attempts, substance use, and any other potential risk factors.
Use objective language: It’s important to use clear and objective language in your documentation. Avoid making assumptions or using judgmental language.
Develop a safety plan: Work with your client to develop a safety plan that includes coping skills, support systems, and emergency contacts. Document the plan in detail in your progress notes.
Reassess regularly: Risk assessment is not a one-time event. It’s important to regularly reassess your client’s mental health status and update their safety plan as needed.
By following these tips, we can ensure that our progress notes effectively document risk assessment and safety planning, and that we are doing our part to keep our clients safe and supported.
