It's 9 PM on a Tuesday. You finished a heavy session three hours ago—a client disclosed suicidal ideation for the first time. You did the assessment. You built a safety plan together. You consulted with a colleague. You did everything right.

But now, staring at the blank progress note, your stomach tightens. How do I write this up? What if I say the wrong thing? What if something happens and this note is the only thing standing between me and a courtroom?

If that scenario sounds familiar, you're not alone—and your instinct to take this seriously is well-founded. Patient suicide is the number one liability risk in mental health care. More than half of families bereaved by suicide believe provider negligence played a role, and roughly one in four consult an attorney. When those cases move forward, it's rarely the clinical decision-making that's on trial. It's the documentation.

The good news? You don't need a law degree to write a solid risk note. You need a framework, the right language, and 10 extra minutes of intentionality. Let's walk through it.

What Makes a "Bulletproof" Risk Note

Think of your suicide risk documentation as answering five questions a reviewer—whether that's a supervisor, an auditor, or an attorney—would ask:

1. Did you assess? Document that you inquired about suicidal ideation, plan, intent, means, and timeline. Include the client's own words when possible. "Client stated, 'I've been thinking it would be easier if I wasn't here, but I don't have a plan'" is far more informative than "denies SI."

2. What's the risk level, and why? State your clinical judgment—low, moderate, or high—and show your reasoning. A strong note connects the dots: "Assessed as moderate risk given history of prior attempt (2021), current hopelessness, and recent job loss. Mitigating factors include strong family support, future-oriented thinking regarding daughter's graduation, and no current access to lethal means."

3. What protective factors exist? Don't skip this. Documenting protective factors demonstrates a balanced clinical picture—not just what's going wrong, but what's keeping the client connected. Reasons for living, social support, treatment engagement, cultural or religious beliefs, and absence of means all belong here.

4. What did you do about it? Detail the interventions you provided in session: safety planning, means reduction counseling, crisis resource review, grounding techniques if the client was dysregulated. If you consulted a colleague or supervisor, document that too—it demonstrates you didn't operate in isolation.

5. What's the plan going forward? Tie your treatment plan directly to the risk assessment. Increased session frequency? Referral to a higher level of care? Coordination with a prescriber? A follow-up call before the next appointment? Each of these shows purposeful clinical action.

When these five elements are present, your note tells a coherent clinical story. When they're absent, even excellent clinical care can look negligent on paper.

The Interventions Section: Where Most Notes Fall Short

Here's where many clinicians leave value (and protection) on the table. You did the work in session—now make sure the note reflects it.

Means reduction is a perfect example. If you discussed firearm access, document the conversation and outcome: "Discussed means restriction. Client reported one firearm in home. Client agreed that her father will hold the gun safe key until further notice. Client verbalized understanding of rationale." That level of specificity matters enormously.

Safety planning should be documented as a collaborative process, not a checkbox. Rather than "safety plan completed," try: "Collaboratively developed written safety plan with client, including identified warning signs (isolation, increased alcohol use), coping strategies (calling sister, walking dog, using Calm app), and emergency contacts (sister Maria, 988 Lifeline). Client was given a copy and agreed to keep it accessible."

Informed refusal is equally important. If a client declines a recommended intervention—say, a psychiatric evaluation or a higher level of care—document it: "Recommended psychiatric consultation given severity of current ideation. Client declined, stating preference to continue outpatient therapy. Discussed risks of declining, including worsening symptoms. Client demonstrated understanding and maintained refusal. Will revisit recommendation next session." This protects you by showing you addressed the clinical need, respected autonomy, and didn't simply let it go.

Phrases That Protect—and Phrases That Don't

Language precision matters more than most of us were taught. Here's a quick reference:

Use these:

• "Client denied suicidal ideation at this time" (clear, time-stamped)

• "Assessed as moderate risk due to [specific factors]; no immediate intent reported" (shows reasoning)

• "Collaboratively developed safety plan; client agreed to [specific steps]" (documents engagement)

• "Consulted with [name/role] regarding risk management; decision to [action]" (shows due diligence)

• "Client's own words: '[direct quote]'" (reduces misinterpretation)

• "Means restriction discussed: [specific outcome]" (documents a standard-of-care intervention)

Avoid these:

• "No SI" with no further context (too vague—assessed how? when?)

• "Contracted for safety" as a standalone intervention (outdated, clinically insufficient, and courts know it)

• "Patient is fine" or "not at risk" without supporting rationale (conclusory without evidence)

• "Denied everything" (dismissive, lacks clinical specificity)

A particular note on safety contracts: Research consistently shows that "no-harm contracts" do not reduce suicide risk. Safety planning—a structured, collaborative coping plan—does. Documenting a safety plan, and the client's engagement with it, is now considered standard of care. If your notes still reference "contracting for safety" as a primary intervention, it's time to update your language and your practice.

Use Structured Tools—and Document That You Did

One of the simplest ways to strengthen your documentation is to incorporate validated screening and assessment tools into your workflow. The Columbia Suicide Severity Rating Scale (C-SSRS), the SAFE-T framework, and the ASQ (Ask Suicide-Screening Questions) each provide structured, evidence-based methods for evaluating risk.

From a clinical standpoint, structured tools catch what unstructured inquiry can miss. A 2025 study found that the ASQ identified 50% more at-risk patients than relying on the PHQ-9 alone (75% vs. 50% sensitivity). That's a meaningful clinical difference.

From a documentation standpoint, noting tool results creates a clear paper trail of due diligence. Compare:

"Assessed suicidal ideation."

vs.

"C-SSRS administered. Client endorsed passive ideation ('I've thought about not being alive') but denied active ideation, plan, or intent. Scored 'low-moderate risk' given ideation in context of current stressors. No prior attempts. Protective factors include strong therapeutic alliance and family engagement."

The second version doesn't take dramatically longer to write, but it tells a fundamentally different story to anyone reviewing the chart.

Many EHR platforms allow you to build templates that prompt for risk factors, protective factors, tool scores, and intervention plans. If your system supports it, create a risk assessment template you can pull into any note. The APA Practice Guidelines and SAMHSA's SAFE-T pocket card are excellent starting points for structuring these templates.

Learning from the Cases That Went Wrong

Malpractice cases involving client suicide follow distressingly predictable documentation patterns. The most common failures aren't clinical—they're clerical:

• Risk was identified but no safety plan was documented

• The note said "SI present" with no elaboration, no risk level, no plan

• There was no evidence the clinician assessed for means access

• The treatment plan didn't change despite elevated risk

• No consultation was sought or documented

In one widely cited case, a therapist's note read "patient having suicidal thoughts" with no recorded safety plan, risk formulation, or follow-up actions. After the client's death, expert witnesses called this a breach of the standard of care. The case settled for over $500,000. The absence of documentation made it appear—fairly or not—that the clinician did nothing.

Conversely, in cases where providers documented thorough assessments, consultations, safety plans, and clinical reasoning, juries have consistently found no negligence—even when the outcome was tragic. Good documentation can't prevent every bad outcome, but it can demonstrate that you provided thoughtful, competent, standard-of-care treatment.

The takeaway isn't to write defensively out of fear. It's to write thoroughly out of habit.

Reframing Documentation as Clinical Thinking

Here's the part that often gets lost in conversations about "CYA" documentation: writing a thorough risk note isn't just a legal exercise. It's a clinical one.

The act of documenting forces you to formalize your risk formulation. It makes you articulate why you assessed risk at a particular level, what you considered, and what your plan is. That process—moving from intuitive clinical impression to structured, written reasoning—makes your decision-making sharper. It's the difference between "I think they're okay" and "Here's why I believe the current level of care is appropriate given these specific factors."

Good notes make you a better clinician. They also happen to protect your license.

Your Documentation Quick-Reference Checklist

Keep this somewhere visible for your next high-risk session:

• Assessed ideation, plan, intent, means, and timeline

• Quoted client's own words about suicidal thoughts

• Stated risk level (low / moderate / high) with clinical rationale

• Listed risk factors specific to this client

• Listed protective factors specific to this client

• Documented tool used (C-SSRS, ASQ, SAFE-T, PHQ-9 Item 9, etc.) and results

• Described interventions provided in session (safety planning, means reduction, grounding, psychoeducation)

• Documented means restriction discussion and outcome

• Noted safety plan details and client's agreement

• Documented any refusals of recommended care and informed consent discussion

• Recorded consultation with colleague, supervisor, or prescriber (if applicable)

• Updated treatment plan to reflect risk level (session frequency, referrals, follow-up contacts)

• Noted follow-up plan (when you'll next see or contact the client)

  
  

One Last Thought

We became clinicians to help people, not to write progress notes. But in the moments that matter most—when a client is at their most vulnerable—your note becomes the bridge between the care you provided and the evidence that you provided it.

Ten minutes of intentional documentation can be the difference between a defensible record and a devastating gap. And more importantly, the discipline of writing it all down makes your clinical thinking stronger in real time.

You're already doing the hard work in the room. Make sure your notes reflect it.

Try This Week: Pull up your last progress note involving any level of suicide risk. Run it against the checklist above. Are there gaps? If so, build a template or "dot phrase" in your EHR that prompts you for each element. Future you—and future you's attorney—will be grateful.

Quick Resources:

• Columbia Suicide Severity Rating Scale (C-SSRS) — Free screening tool and training

• SAMHSA SAFE-T Pocket Card — Structured assessment framework

• 988 Suicide & Crisis Lifeline — Client-facing crisis resource

• APA Practice Guidelines for Suicidal Behavior — Clinical and documentation standards

• Stanley-Brown Safety Planning Intervention — Evidence-based safety planning protocol

Disclaimer: This article provides general educational information for behavioral health clinicians and is not legal advice. Documentation requirements vary by jurisdiction, license type, and practice setting. Consult your state licensing board, malpractice carrier, and clinical supervisor for guidance specific to your situation.