Suicide Risk Documentation: Screen, Assess, Plan, Document
By WellNotes Clinical Team. Facts checked against the linked pages and the sources below. Last reviewed . Last updated: . See sources.
How do you document suicide risk?
Suicide risk documentation usually follows four steps: record the screening tool and its result, document the risk assessment and your clinical reasoning, record the safety plan made with the client, then capture all of it in the progress note and, where it fits, the diagnosis code. This hub links a WellNotes guide for each step.
If someone is in immediate danger, call 911 or local emergency services. For crisis support, call, text or chat 988 (Suicide and Crisis Lifeline).
These pages are documentation references, not clinical guidance. Your training, your supervisor, your organization’s protocol and the law where you practice decide how you screen for, assess and respond to suicide risk. Each guide names the primary source behind it, such as the Columbia Lighthouse Project for the C-SSRS and the Stanley-Brown Safety Planning Intervention for safety plans.
From screen to note: the documentation workflow
Each step leaves a record the next step builds on:
- Screen. Record the tool and version, the time frame, the result as the tool reports it, and what you did next.
- Assess. When a screen or the session raises concern, document the assessment that follows: risk and protective factors, current status and the reasoning behind your conclusion.
- Plan. If you and the client make a safety plan, record that it was made, reviewed and shared, and where the plan itself is kept.
- Document and code. Carry the screen, assessment and plan into the progress note, and into the diagnosis code and discharge summary where they apply.
Screen
Screening tools flag who needs further evaluation. These guides cover how to record the result.
Assess
The assessment documents that hold the risk findings and your reasoning.
- Risk assessment templateRisk factors, protective factors, current status, safety plan and recommendations, with a filled example.
- Mental status exam templateEvery MSE domain, including thought content, where suicidal or homicidal ideation is recorded, with two filled examples.
- Intake assessment templateThe first-session assessment: presenting problem, history, mental status, diagnostic impressions and recommendations.
- Biopsychosocial assessment templateBiological, psychological and social prompts, a filled example with a risk screen, and a formulation guide.
Plan
The plan made with the client, and how to document it.
Document and code
Where the findings end up: the diagnosis code, the closing summary and the session note.
- ICD-10 code for suicidal ideation (R45.851)R45.851, the Excludes1 note for suicide attempt (T14.91) and the Z91.5 history codes.
- Therapy discharge summary templateWhat a closing summary records, including risk status at the last contact and the aftercare and crisis information given, with three filled examples.
- Free therapy progress note generatorDrafts a SOAP, DAP or BIRP progress note from what you type, for the session that included the screen, assessment or plan.
Frequently Asked Questions
Is a positive suicide screen the same as a risk assessment?
No. A screen such as the C-SSRS screener or PHQ-9 item 9 identifies who needs further evaluation. The assessment that follows is the clinician’s evaluation of risk and protective factors and current status, documented with the reasoning behind it and carried out under your setting’s protocol.
Where does a suicide screen go in a progress note?
Record the tool and version, the time frame, the result as the tool reports it and the actions you took. In a SOAP note the result usually goes in Objective and your interpretation in Assessment; in a DAP note, in Data and Assessment.
When is ICD-10-CM code R45.851 used?
R45.851, Suicidal ideations, is a symptom code. Whether it is reported depends on what is documented, the other diagnoses and the ICD-10-CM Official Guidelines. The R45.851 guide covers its Excludes1 note for a suicide attempt and the history codes.
Does WellNotes assess suicide risk?
No. WellNotes does not screen clients, score tools or decide a risk level. You do the screen and the assessment. WellNotes drafts notes from what you type or dictate, and you review and edit every note.
Sources
- Columbia Lighthouse Project: about the C-SSRS
- Columbia Lighthouse Project: C-SSRS for communities and healthcare (versions and free use)
- Stanley-Brown Safety Planning Intervention (Stanley B, Brown GK): suicidesafetyplan.com
- Brown G, Stanley B. Safety Planning Guide: A Quick Guide for Clinicians. Suicide Prevention Resource Center
- 988 Suicide and Crisis Lifeline: how to get help
- SAMHSA: 988 Suicide & Crisis Lifeline
- CMS and NCHS: ICD-10-CM Official Guidelines for Coding and Reporting, FY2027 (PDF)
- CDC NCHS: ICD-10-CM and the ICD-10-CM Browser Tool
For documentation support, not clinical or legal advice. These pages do not tell you how to assess or manage suicide risk. Follow your training, your supervisor, your organization’s protocol and the law where you practice.
Draft the progress note for the session
Type what happened in the session, including the screen, your assessment and any plan made, and the free therapy progress note generator drafts a SOAP, DAP or BIRP note. You review and edit every note before you use it.