Name: Suicidal ideation — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

The defensible suicide-risk chart isn't a one-line "denies SI." It documents a validated screen (and that a refusal was treated as risk), a targeted medical evaluation, the safety measures and 1:1 observation, means-restriction counseling, and a real safety plan — not a no-suicide contract.

01What's at stake

Suicide is a leading cause of death in young people, and risk is frequently occult — a large share of positive screens come from patients who arrived with a medical complaint. The traps are: not screening, treating a refusal to answer as reassurance, missing an occult ingestion behind the presentation, an unsafe room/elopement, and discharging without means counseling and follow-up.

02Can't-miss points

Occult ingestion / medical mimic — vitals and exam can unmask it (toxidromes, eating disorder, infection); screen acetaminophen and salicylate in any intentional ingestion.
Refusal to answer = risk, not a negative screen.
The imminent-risk patient who elopes — an acute positive screen means they can't leave until evaluated.
Missed self-harm injury — full skin exam; CTA neck for significant hanging.

03Screening & risk assessment

Use a validated tool — ASQ or the Columbia (C-SSRS) screen; an affirmative (or refused) screen triggers a brief suicide safety assessment. → screen, don't eyeball
Risk vs protective factors — prior attempts, psychiatric/substance diagnoses, access to lethal means (a home firearm raises risk 3–4×), triggering events; coping skills and supports are protective.
Distinguish ideation from a plan/preparation/attempt; assess access to means.
Interview the patient alone for sensitive topics, and explain the limits of confidentiality.

Skip the typing

Work the case in the Suicidal Ideation / Self-harm Workup — it records the C-SSRS, the acetaminophen/co-ingestion screen, collateral, and the safety plan, and assembles an MDM that documents the risk assessment, safety measures, and disposition.

04Medical evaluation & ED safety

"Medical clearance" = targeted, not reflexive. Routine labs rarely change disposition; test by history/exam — acetaminophen/salicylate levels for ingestion, pregnancy test, and a complete skin exam for self-harm injury.
Make the room and patient safe — remove ligatures, sharps, and medications; patient scrubs; disconnect a usable insulin pump; 1:1 observation (caregiver observation alone is not sufficient) and keep imminent-risk patients in sight.
Means-restriction counseling — firearms (locked, unloaded, ammunition separate), medications, sharps; provide lockboxes/devices where available.

05Disposition & what to document

Risk-stratified, least-restrictive disposition: low → discharge with a safety plan and follow-up; moderate/high → mental-health evaluation, admission, or ED-to-ED transfer with safety maintained and the risk assessment handed off.
Use a Stanley-Brown safety plan, not a no-suicide contract; arrange prompt outpatient follow-up and give crisis resources (988).

▼ weak

"Denies SI. Medically cleared. Safe for discharge."

▲ defensible

"C-SSRS administered: prior-week ideation, no current plan; not an acute positive. Risk/protective factors documented; access to means reviewed. Interviewed alone; confidentiality limits explained. Targeted medical eval — acetaminophen/salicylate negative (reported ingestion), full skin exam without injury; no reflexive labs. Room made safe and 1:1 observation initiated (not caregiver-only). Means-restriction counseling given (firearm locked/removed). Mental-health evaluation completed; Stanley-Brown safety plan completed, 988 provided, outpatient follow-up arranged."

06Where charts fail

"Denies SI" without a validated screen, or treating a refusal as a negative.
Reflexive "medical clearance" labs instead of targeted testing — or missing the acetaminophen/salicylate co-ingestion.
Relying on caregiver observation, or an unsafe room (ligatures/sharps/meds, insulin pump left on).
A no-suicide "contract" instead of a real safety plan.
No means-restriction counseling, no documented follow-up, and no risk-assessment handoff on transfer.

07Sources

Foster AA, Ketabchi B, Hoffmann JA. Evaluation and management of suicidal ideation and self-harm in children in the emergency department. Pediatric Emergency Medicine Practice (EB Medicine). 2024;21(3).
Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170-1176.
Doupnik SK, Rudd B, Schmutte T, et al. Association of suicide prevention interventions with subsequent suicide attempts and linkage to follow-up care. JAMA Psychiatry. 2020;77(10):1021-1030.
American Academy of Pediatrics & American Foundation for Suicide Prevention. Suicide: blueprint for youth suicide prevention. 2024.

Suicidal ideation: documentation that holds up