Suicide Risk Assessment by Residents: Deficiencies of Documentation.

OBJECTIVE: The authors sought to assess the documentation of suicide risk assessments performed by psychiatry residents in a psychiatric emergency service (PES) and to identify differences in documentation between previously used paper charts and a new electronic medical record (EMR) system based on the Columbia Suicide Severity Rating Scale (C-SSRS)-risk assessment version. METHODS: This study is a retrospective chart review of psychiatric evaluations performed by psychiatry residents during a 1-year period in the PES of a large, urban, academic medical center. The sample was selected by a systematic random sampling technique from a total of 3931 evaluations performed on adult patients during the study period. The suicide risk assessments were evaluated using data regarding demographics, process indicators identified from the C-SSRS, and diagnoses. RESULTS: A total of 300 charts were reviewed. Only 91% of the evaluations contained documentation of suicidal ideations (either admitted or denied); 5 other variables were documented in more than 50% of the evaluations: treatment status (95.3%), presence/absence of previous suicide attempts (84.6%), recent event-denies (56%), history of recent negative events (55%), and suicidal behavior-denies (53%). Additionally, 2 risk factors and 3 protective factors were documented in over 25% of the evaluations. CONCLUSION: Documentation was deficient in multiple areas, with even the presence/absence of suicidal ideations not being documented in all evaluations. Use of an EMR with built-in "clickable" options selectively improved documentation especially regarding risk and protective factors adapted from the C-SSRS. Emphasis on documentation of assessments is paramount while training residents in suicide risk assessment.