Today I share with you documentation tips and start with the most challenging scenario, documenting situations involving patients at risk of suicide. Documentation, however, is simply the last step in a process of assessment and formulation, the typing or writing down of data obtained and conclusions drawn. With that in mind, I start ‘upstream’ with a review of Therapeutic Risk Management (TRP) and work my way towards documentation tips. Today I present you with an overview, along with some practical tips, and in later posts delve in detail into specific aspects of TRM and documentation.

Weekly Photo

Last couple of weeks I’ve spent in Poland. I took my mother, now quite elderly, to visit relatives. While I was there, I briefly traveled to a couple of cities I’ve never visited before. The photo shows a close-up of a heart, about 12 feet high, made up of hundreds of individual tiles, each baked by a different person as part of a street art project in Wroclaw, Poland.

Therapeutic Risk Management

As articulated by Grant and Lusk, Therapeutic Risk Management “ensures that the role and competence of the clinician is aligned with legal concerns surrounding suicide risk in psychiatric practice.” TRM’s foundation is meeting the standard of care, described as “A psychiatrist is required to possess and exercise, in both diagnosis and treatment, that reasonable degree of knowledge and skill ordinarily possessed and exercised by other members of his profession in similar circumstances.” Note the specifiers in this rather lengthy statement.

  • “diagnosis and treatment”: this lets us know that we’re judged not only by our management interventions. We also need to show we’ve conducted reasonable diagnostic and risk assessments and generated a reasonable differential list and working diagnosis as well as risk formulation. The thinking goes that good assessment and diagnosis is more likely to lead to better management and treatment.
  • “ordinarily possessed and exercised”: this means that each of us is judged in relation to an average member of our profession. We need to show we perform at the level of a reasonable and prudent professional. We don’t have to show exemplary or heroic performance.
  • “by other members of his profession”: we are judged in relation to other members of our specialty and/or subspecialty. If you are, for example, a family practitioner treating a patient with major depressive disorder, your performance is judged against other family practitioners. As psychiatrists, we are regarded as specialists and need to meet a higher standard of knowledge and skill. If you are subspecialist, for example, a Child and Adolescent Psychiatrist or Geriatric Psychiatrist, you will be judged in relation to that professional cohort.
  • “in similar circumstances”: you are judged by your setting. If you are a psychiatrist working in a rural area with a paucity of subspecialists or diagnostic assessment tools or treatment options, you are judged in relation to that setting. If you work at a university medical center with access to all kinds of resources, you are judged in relation to that setting. Circumstance also includes urgency or acuity. In a medical emergency fewer diagnostic or treatment options might be available than if more time were available.

If you are ever named in a medical malpractice lawsuit, the court (judge or jury) will determine whether three criteria for standard of care were met:

  1. Suicide risk assessment process was reasonable
  2. Patient’s suicide attempt was foreseeable
  3. Reasonable treatment steps (precautions) were taken

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Problems with Risk Assessment

Here are examples of possibly negligent risk assessments:

  • Conducting a single suicide assessment without documenting follow-up assessments and ongoing monitoring
  • Patient discharged from hospital without pre-discharge suicide assessment
  • Medical notes by other staff not read and problems written there not addressed by psychiatrist writing discharge order
  • Case of high risk patient not discussed (with proper informed consent) with family and staff, and large discrepancies in history or presentation not addressed
  • Not responding to messages of concern from family / friends, including because you do not have authorization to release information to them. Remember you can always receive information even if you do not disclose private information.

Problems with Foreseeability

  • Not addressing ‘warning signs’ in high risk patients
    • Patient engaged in increasingly risky, violent, self-destructive or self-injurious behaviors
    • Patient voicing new or heightened suicidal ideation
    • Patient attempts suicide, even if of low lethality (note that patients do not always accurately perceive level of lethality)
    • Patient with auditory command hallucinations
    • Patient with clear delusional risk-conferring beliefs
    • Family or friends communicate heightened risk factors
  • Not assessing for potential triggers / hazards
    • Foreseeable changes in circumstance that patient’s history suggests can lead to a crisis

Problems with Treatment (Precautions Taken)

Despite evidence of elevated risk no steps taken to update treatment plan and implement changes. The following are examples of possible changes not made:

  • Patient’s medication regimen not changed
  • Family and friends not engaged to monitor and support
  • Acute crisis triggers not addressed / resolved
  • Access to lethal means not restricted
  • Hospitalization or increased level of care not considered
  • Discharged from hospital without adequate discharge plan
  • Steps not taken to optimize transition of patient from inpatient to outpatient care
  • High-risk patient lost to follow-up without urgent efforts to return to care
  • Not discussing diagnosis with patient (and family), or its seriousness or possible consequences
  • Abandoning patient without proper transition to another provider

Problems with Documentation

  • Repetitive brief statements or acronyms (e.g., No SI/HI) used without further evidence of an assessment being done
  • Overuse or misuse of ‘No-Harm’ contracts: no evidence of benefit
    • If you decide on a ‘No-Harm’ contract, document your reasoning
    • Example of justification: “Because of the patient’s long-term therapeutically engaged relationship with me, his motivation to sign a ‘No-Harm’ contract is seen as a suicide protective factor.”
    • Remember that a “No Harm” contract differs from a Safety Plan (which is beneficial)
  • Checked items on a checklist of risk factors or suicide-related symptoms
    • Plaintiff’s attorney will find other risks or symptoms not included on your list. And in EMR you may fail to update checklists or retain other repetitive content
  • No explanation of incongruities in the patient’s presentation
    • If different staff record patient’s presentation quite differently, or if aspects of patient’s presentation are incongruent (for example, patient states he’s fine but remains anergic and dysphoric), or if the patient changes dramatically from one day to another, all these incongruities should be further assessed and documented.

Improve Your Documentation

With all this as background, I ask that you brainstorm your own list of how to improve your documentation. Of course, this may have become clear to you, many documentation shortcomings are really shortcomings in assessment and management. Here is a partial list of possible improvements.

  •  Conduct and document systematic suicide assessments
    • Do them at the start of treatment, when patient is hospitalized, prior to patient’s discharge from hospital, with significant worsening and dramatic improvement, since both can signify increased suicide risk
  • Include synthesis or formulation of findings and relate them to your treatment plan
    • Don’t raise issues in history that you leave unaddressed in the treatment plan
    • Justify suicide rating of low, moderate or high risk
    • Clarify incongruities in levels of individual symptoms or a significant change from one day/session to the next
  • Include objective signs of improvement
    • Insert quotes of patient’s statements, especially ones that support your clinical impression, whether it is that the patient is doing poorly or well. Quotes show that you actually spent time with the patient, listened and incorporated their statements into your impression.
    • Document patient’s future focus, if present, since a future focus can support a judgment of a lowered risk of suicide
    • Include objective signs of patient’s improvement, such as attending groups, shaving, brushing hair, making bed, interacting with patients and staff, calling family, planning next steps post discharge, making eye contact, brighter affect, improved impulse control, lessened irritability, or improved appetite and sleep.

Well, that’s a start, isn’t it?

Until next time,

Dr. Jack


Today’s Quotes

“… when politicians and generals lead nations into war, they almost invariably assume swift victory , and have an enduring tendency not to foresee problems, that in hindsight, seem obvious.”
– Adam Hochschild

“When you do great things, think as if you missed the mark by an inch; walk as if you are yet to face the greatest task; talk as if you are yet to have the best preparation for the momentous moment and dream as if you are fighting a battalion of tasks”
– Ernest Agyemang Yeboah