Clinical practice · July 13, 2026 · 7 min read
How to Document a Suicide Risk Assessment (With a Defensible Structure)
The domains a risk assessment note must cover, how to write a formulation instead of a score, and a safety-plan structure you can reuse.
When risk enters a session, your documentation does two jobs at once: it structures your clinical thinking in the moment, and it protects you later by showing the reasoning behind your decisions. A checklist score does neither on its own. Here's the structure that does both.
Cover the domains, then formulate
Document ideation (frequency, intensity, controllability), plan (specificity, lethality), intent, access to means, history (prior attempts are the strongest single predictor), amplifiers (intoxication, recent loss, agitation, insomnia, hopelessness), and protective factors (reasons for living, connection, engagement in care).
Then write a formulation, not a verdict:
"Acute risk assessed as moderate: active ideation daily with a vague method and no stated intent; no access to firearms; protective factors include care of her son and strong engagement in treatment. Chronic risk elevated given 2022 attempt. Plan: safety plan completed and reviewed (below), means counselling re: medication storage, follow-up moved to 4 days."
That paragraph, with a date and signature, is what defensible looks like.
The six-step safety plan
1. Personal warning signs 2. Internal coping strategies 3. People and places for distraction 4. People to ask for help 5. Professional and crisis contacts — in Canada, 9-8-8 by call or text, 24/7 6. Means restriction agreed with the client
Document the client's engagement with the plan. A no-suicide contract is not a safety plan and offers no protection, clinical or legal.
What software should contribute
Instruments with risk items should flag them automatically (PHQ-9 item 9, EPDS item 10), your note system should have a purpose-built risk template so 2 am documentation follows the same structure as 2 pm documentation, and the record must lock on signature. PsychApp ships a structured Risk Assessment & Safety Plan template with all six steps, automatic risk flags on assessments, and locked signed notes with addenda. See the clinical templates.
Frequently asked questions
Do I need to document risk when the client denies ideation?
Yes — a one-line negative finding ('screened for SI, denied; no plan, intent or means; risk assessed as low') shows the assessment happened. Silence in the chart reads as an assessment that never occurred.