By Miranda, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed clinical nurse.

Last updated: April 11, 2026

Charting Suicidal Ideation and Safety Assessments: A Nursing Guide

Your patient just said something that scared you. Perhaps they expressed, "I don't want to be here anymore" during a routine check-in, or they directly mentioned thoughts of self-harm. Your heart rate increases, and your mind races through the clinical steps to take - while you also recognize the need to document this situation accurately. This charting category requires precise documentation for both patient safety and your license. The good news is that safety assessment documentation follows a clear, structured framework. Once you understand the required elements, you'll never hesitate in front of the chart again.

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Why This Matters

Regulatory bodies: The Joint Commission (NPSG 15.01.01), Centers for Medicare & Medicaid Services (CMS), State Mental Health Codes, ANA Code of Ethics

Suicide ranks as a leading cause of death in the United States, prompting the establishment of inpatient psychiatric units to keep suicidal patients safe. The Joint Commission's National Patient Safety Goal 15.01.01 requires organizations to identify patients at risk for suicide and implement evidence-based processes to reduce that risk. CMS conditions of participation mandate documentation of patient safety assessments as part of the psychiatric evaluation. State mental health codes link involuntary hold criteria to documented findings of danger to self or others; the specificity of your charting can determine whether a legal hold is upheld or overturned. The Columbia Suicide Severity Rating Scale (C-SSRS) has become the most widely adopted standardized screening tool, used in over 500 studies and mandated by many institutions. SAMHSA's SAFE-T protocol and the NIMH's Ask Suicide-Screening Questions (ASQ) toolkit offer additional structured frameworks. The Stanley & Brown Safety Planning Intervention has replaced the outdated no-harm contract in evidence-based practice; multiple studies demonstrate that safety plans reduce suicidal behavior, while no-harm contracts lack demonstrated efficacy and may create a false sense of security. Your documentation of safety assessments serves as the legal record of your findings, actions taken, and the plan in place. Incomplete documentation in this area creates clinical risk for the patient and legal risk for you.
  1. National Patient Safety Goals - Suicide Prevention — The Joint Commission (2025)
  2. The Columbia Suicide Severity Rating Scale (C-SSRS) — Columbia University / Columbia Lighthouse Project (2024)
  3. Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk — Stanley B, Brown GK. Cognitive and Behavioral Practice. 2012;19(2):256-264 (2012)
  4. SAFE-T: Suicide Assessment Five-Step Evaluation and Triage — Substance Abuse and Mental Health Services Administration (SAMHSA) (2009)
  5. ASQ Suicide Screening Toolkit — National Institute of Mental Health (NIMH) (2024)

What Safety Assessment Covers

Safety assessment in psychiatric nursing involves a structured evaluation of a patient's risk of harm to self or others. It encompasses four primary domains: suicidal ideation (SI), homicidal ideation (HI), hallucinations (auditory, visual, and command), and self-harm behaviors. In the NurseChartingPro app, the safety category includes an SI flag, HI flag, AVH (auditory/visual hallucination) flag, safety plan status, and BERT flag, along with a conditional alert that triggers when any finding is positive. This alert prompts the nurse to complete all documentation elements before proceeding. Safety assessment is not a one-time event; it occurs at admission, every shift, with any change in status, after PRN medication administration, and before any privilege change (grounds passes, visitor access, discharge). Each assessment requires its own documentation entry, addressing all necessary elements. A negative screen still requires documentation, but the requirements differ for a negative screen compared to a positive finding. "Denies SI" serves as a valid negative screen response. However, "denies SI" does not suffice as documentation if the patient endorsed suicidal ideation yesterday and you are documenting today's reassessment. Context matters, and this page will detail what to include in each situation.

Suicidal Ideation - The Core Category

Documenting suicidal ideation (SI) is the most scrutinized element in any psychiatric chart. When documenting a positive finding or a negative screen, the level of detail expected exceeds that of any other charting category.

Passive Versus Active Suicidal Ideation

The distinction between passive and active SI holds clinical significance and requires explicit documentation. Passive SI refers to the patient's wish to be dead or a desire not to be alive, without any plan or intention to act. Common expressions include "I wish I wouldn't wake up," "My family would be better off without me," or "I don't see the point anymore." Active SI indicates that the patient is contemplating suicide and may have a plan, intent, means, or timeline. The severity spectrum ranges from "I've thought about taking pills" (active ideation with a plan but unclear intent) to "I have a plan and I intend to do it when I get out" (active ideation with a plan, intent, and timeline). Document the patient's exact words whenever possible. For example, "Patient states: 'I just wish I could go to sleep and not wake up'" is more defensible and clinically useful than "patient endorses passive SI." Both the clinical label and the verbatim quote are necessary.

The 8 Required Elements of SI Documentation

When a patient endorses suicidal ideation, your documentation must address all 8 elements to be considered complete: 1. Presence - Does the patient endorse SI? Document the screening question you asked and the patient's response, including direct quotes. 2. Type - Passive or active? "Wishes she were dead" versus "has thought about a specific method." 3. Plan - Does the patient have a plan for how they would attempt suicide? If yes, document the plan specifically. If no, document "denies plan." 4. Intent - Does the patient intend to act on the ideation? Intent is separate from plan; a patient can have a plan without intent ("I've thought about it but I wouldn't do it") or intent without a detailed plan ("I'm going to do something when I get out"). 5. Means - Does the patient have access to the means described in their plan? On an inpatient unit, means restriction is part of the environment. Document what means the patient has described and what restrictions are in place. 6. Timeline - Is the ideation current, recent, or historical? Has the patient identified a timeframe? "When I get discharged" differs from "right now." 7. Protective Factors - What reasons does the patient identify for living? Children, religious beliefs, fear of pain, pets, future goals. Document their words: "States she would never do it because of her daughter." 8. Interventions Initiated - What actions did you take? Notify the provider, increase observation level, initiate a safety plan, remove items from the room, request 1:1, or administer PRN medication. Every positive SI finding should trigger at least one intervention, and that intervention must be documented.

Using the C-SSRS

The Columbia Suicide Severity Rating Scale (C-SSRS) is the most widely adopted standardized screening tool in psychiatric settings. Many institutions require C-SSRS screening at admission and at specified intervals. The scale progresses through a series of yes/no questions that systematically assess the severity of suicidal ideation: Question 1: Wish to be dead ("Have you wished you were dead or wished you could go to sleep and not wake up?") Question 2: Nonspecific active suicidal thoughts ("Have you actually had any thoughts of killing yourself?") Question 3: Active SI with method but no plan or intent Question 4: Active SI with some intent to act, without a specific plan Question 5: Active SI with specific plan and intent Document the C-SSRS score, which question the patient endorsed up to, and the corresponding clinical details. For example: "C-SSRS administered. Patient endorsed through Question 2 - reports thoughts of killing herself but denies any method, plan, or intent. Score consistent with active ideation, low severity. Last endorsement within the past week." The C-SSRS also screens for suicidal behavior (actual attempts, interrupted attempts, aborted attempts, and preparatory behavior). If any of these are endorsed, document the details including the method, medical severity, and circumstances.

Example SI Documentation

Here is what a complete SI documentation entry looks like for a patient who endorses passive ideation during a shift assessment: "Safety screening performed. Patient endorses suicidal ideation - passive. States: 'I'm tired of fighting this. I wish I could just disappear.' Denies active ideation. Denies plan. Denies intent to act. Denies access to means (personal belongings searched at admission, sharps restriction in place). Timeline: ideation has been present 'for weeks' per patient, with no change in intensity today. Protective factors identified: daughter (age 6), states 'I would never leave her.' C-SSRS administered: endorsed through Question 1 (wish to be dead), denied Questions 2-5. Interventions: MD notified of continued passive SI. Safety plan reviewed with patient - patient able to identify warning signs and coping strategies. Observation level maintained at Q15min per MD order. Patient encouraged to notify staff if ideation intensifies. Will reassess next shift and PRN." Notice that every one of the 8 elements is addressed, the patient's exact words are quoted, the standardized tool is referenced, and the interventions are specific.

Homicidal Ideation

HI documentation follows a parallel structure to SI documentation. When a patient endorses thoughts of harming another person, document the presence and exact content (quote the patient), target (named person or general), plan, intent, means/access, timeline, and interventions initiated. The clinical and legal stakes are equally high. In many jurisdictions, Tarasoff duty (or its state-specific equivalent) requires clinicians to take reasonable steps to warn an identifiable potential victim when a patient makes a credible threat. Your documentation must reflect your assessment of the threat, whether a specific target was identified, and adherence to your facility's Tarasoff/duty-to-warn protocol. Document the notification chain: provider notified, charge nurse notified, risk management contacted, and (if applicable) that the identified potential victim or law enforcement was notified per policy and state law. Example: "Patient endorses homicidal ideation toward ex-partner. States: 'If I ever see him again, I'm going to kill him.' Specific target identified (ex-partner, [name]). Plan: denies specific plan when asked directly. Intent: 'I don't know, I just get so angry.' Means: patient does not currently have access to weapons (inpatient, belongings searched). Timeline: ideation is recurrent, intensifies when discussing custody dispute. Interventions: MD notified. Social work consulted for Tarasoff evaluation. Risk management notified per facility protocol. Patient placed on Q15min observation. Will reassess after social work evaluation."

Auditory and Visual Hallucinations

Documenting hallucinations requires more than simply stating, "patient reports AVH." The clinical significance of a hallucination relies heavily on the details you provide.

Type and Content

Document the sensory modality: auditory (hearing voices or sounds), visual (seeing things), tactile (feeling sensations on or under the skin), olfactory (smelling odors), or gustatory (tasting substances). Auditory hallucinations frequently occur in psychiatric populations. For each hallucination, document the content: What does the patient hear or see? How many voices are present? Are they recognizable or unfamiliar? What do they say? Direct quotes are essential: "Patient reports hearing two male voices that are 'arguing about whether I should leave.'" Visual hallucinations require a medical workup alongside psychiatric evaluation, as they are more commonly linked to organic etiologies (delirium, substance withdrawal, neurological conditions) than to primary psychotic disorders.

Command Hallucinations

Command hallucinations - voices that tell the patient to do something - are the most clinically urgent type of hallucination and require the most detailed documentation. Document: What are the commands? (Quote the patient.) Is the patient able to resist the commands? Has the patient ever acted on the commands? Are the commands directing self-harm or harm to others? Example of command hallucination documentation: "Patient reports auditory hallucinations - one male voice, unfamiliar, present intermittently throughout the day. Voice is commanding in nature. Patient states: 'It tells me to hurt myself. It says I should use the cord from the window blinds.' Patient reports being able to resist the commands currently but states they are 'getting louder and harder to ignore.' Denies history of acting on command hallucinations. Specific means referenced (cord) - environmental safety check completed, all cords secured and out of reach. MD notified of command AVH with self-harm content. Observation level increased to 1:1 per MD order. PRN olanzapine 5mg IM offered and administered. Will reassess in 30 minutes and ongoing." This entry documents the command content, the patient's ability to resist, history of compliance with commands, the specific means referenced, environmental intervention, provider notification, and medication response - all critical elements.

Patient Response to Hallucinations

Document the patient's responses to the hallucinations. Are they talking back to the voices? Covering their ears? Appearing distracted during conversation? Responding to internal stimuli (the clinical phrase for observable behavior suggesting hallucination activity)? These behavioral observations corroborate the patient's self-report and provide objective data. Document both the subjective report ("patient states he hears voices telling him to leave") and the objective observation ("observed talking to self, looking toward an empty corner of the room, appearing intermittently distracted during the interview, pausing mid-sentence as if listening").

1:1 Observation and Safety Plan Documentation

When a patient's risk level warrants continuous observation or a structured safety intervention, documentation requirements increase significantly.

1:1 Observation Documentation

One-to-one (1:1) observation means a staff member remains with the patient at all times, within arm's reach. Documentation must reflect this continuous presence. Most facilities require entries at 15-minute intervals (Q15min) even during 1:1 observation. Each entry should include the time, the patient's location, the patient's activity, the patient's behavior and mood, and any safety concerns observed. Example of four consecutive Q15min entries during 1:1 observation: "1400 - 1:1 observation. Patient in room, lying in bed. Awake, eyes open. Calm, cooperative. Denies SI/HI when asked. No safety concerns. 1415 - 1:1 observation. Patient in room, sitting on edge of bed. Tearful. States: 'I keep thinking about what I did.' Encouraged to use coping strategies from safety plan (deep breathing, calling sister). Patient practiced deep breathing x3 with staff. Affect improved slightly. 1430 - 1:1 observation. Patient in hallway, walking to dayroom. Calm. Engaged briefly with peer. Ate snack. No safety concerns. 1445 - 1:1 observation. Patient in dayroom, watching TV. Alert, calm. No behavioral concerns. Denies current SI when asked." Notice that each entry stands as its own observation - not a summary of the hour. Each one describes where the patient is, what they are doing, and their current behavioral and emotional state. This documentation standard withstands regulatory scrutiny.

Safety Plans

The Stanley & Brown Safety Planning Intervention has replaced no-harm contracts in evidence-based psychiatric practice. A safety plan is a collaborative document developed with the patient that identifies warning signs indicating a crisis is developing, internal coping strategies the patient can use independently, people and social settings that provide distraction, individuals the patient can contact for help (friends, family, sponsors), professional and emergency contacts, and environmental safety steps (means restriction). Your documentation should reflect that the safety plan was developed or reviewed, that the patient participated, and that the patient can articulate the key elements. Avoid simply writing "safety plan in place." Instead, document: "Safety plan reviewed with patient. Patient identifies warning signs (isolation, increased irritability, sleep disruption). Coping strategies discussed: deep breathing, journaling, calling sister. Patient can identify three people she can contact if in crisis. Emergency numbers reviewed. Patient verbalized understanding and agreement with the plan. Copy provided to patient. Safety plan filed in chart." Do not use the phrases "no-harm contract" or "contract for safety" in your documentation. These terms reflect outdated practices that lack evidence of effectiveness and may create a false sense of security for clinicians. The Joint Commission and major psychiatric organizations recommend safety planning as the standard of care.

Common Mistakes

"Denies SI" as the Only Screening Documentation

Weak: Denies SI/HI.
Strong: Safety screening performed. Asked: "Are you having any thoughts of hurting yourself or wanting to die?" Patient states: "No, I'm not thinking about that." Denies SI - no passive or active ideation. Denies HI. Denies AVH. C-SSRS: negative screen. Safety plan remains in place. Observation level: Q15min.

"Denies SI" does not document the specific question asked, the patient's response, or the assessment conducted. A surveyor or attorney cannot determine from "denies SI" whether you actually screened the patient or simply carried forward a previous entry. The strong example clearly shows the screening question, the patient's response, the standardized tool result, and the current safety status.

Positive SI without all 8 required elements

Weak: Patient endorses SI. States she wants to die. MD notified.
Strong: Patient endorses suicidal ideation - passive. States: "I don't want to be alive anymore." Denies active ideation. Denies plan. Denies intent to act. Denies access to means (belongings searched at admission). Ideation has been present "since last week" per patient. Protective factors: son (age 12), states "he needs me." C-SSRS: endorsed Q1, denied Q2-Q5. MD notified. Safety plan reviewed. Observation maintained at Q15min.

The weak example documents the presence of SI and one intervention but omits type (passive vs. active), plan, intent, means, timeline, protective factors, and the standardized screening tool. If this patient later attempts suicide, the incomplete documentation suggests an incomplete assessment.

1:1 Observation Documentation Gaps

Weak: 1:1 observation maintained from 1400-1800. Patient calm and cooperative throughout. No safety concerns.
Strong: Four hours of individual Q15min entries documented the patient's location, activity, behavior, mood, and any safety concerns at each specific moment.

A single note covering four hours of 1:1 observation does not provide defensible documentation. If an event occurred at 1530, there is no contemporaneous record of the patient's status at that time. Each Q15min interval requires its own entry to demonstrate continuous monitoring.

Using "no-harm contract" language

Weak: No-harm contract signed. Patient agreed not to hurt herself.
Strong: Safety plan developed collaboratively with patient. Patient identifies warning signs (isolation, increased hopelessness), coping strategies (deep breathing, calling sister, walking), and emergency contacts (crisis line, sister's phone number, 911). Patient verbalized understanding of plan. Copy provided.

No-harm contracts lack evidence of effectiveness in reducing suicide risk. Major psychiatric organizations and the Joint Commission recommend against their use. The safety planning intervention (Stanley & Brown, 2012) serves as the evidence-based alternative. Using outdated terminology in charting indicates outdated practice.

Not Documenting Command Hallucinations Specifically

Weak: Patient reports auditory hallucinations. PRN given.
Strong: Patient reports auditory hallucinations - one voice, male, unfamiliar, commanding. Content: "It tells me to walk into traffic." Patient reports being able to resist currently. Denies acting on commands in the past. Environmental safety maintained (unit is locked, outdoor privileges restricted). MD notified of command AVH with self-harm content. Observation increased to 1:1 per MD order. PRN risperidone 2mg PO administered at 1430. Will reassess in 30 minutes.

Simply stating "reports auditory hallucinations" does not inform the treatment team whether the voices are benign background noise or commands to self-harm. Command hallucinations with self-harm or violent content require immediate escalation and specific documentation of the command content, the patient's ability to resist, and the interventions taken.

Ms. DominguezAge 34 — Major depressive disorder, recurrent, severe; admitted with passive suicidal ideation
fictional patient

Scenario

You are the evening shift nurse on an adult psychiatric unit. Ms. Dominguez was admitted yesterday after presenting to the ED with suicidal ideation. She is on day 2 of her admission. During your shift safety assessment, she endorses passive SI but denies active ideation. She denies HI and AVH. A safety plan is in place from admission. Observation level is Q15min per provider order. Here is the full safety assessment documentation for your shift.

Chart Entry

Safety Assessment - 1600

Suicidal Ideation: Safety screening performed using C-SSRS. Patient endorses suicidal ideation - passive. States: "I still don't want to be here. I keep thinking my kids would be better off without me." Denies active suicidal ideation. Asked directly: "Are you thinking about killing yourself?" Patient responds: "No, not like that. I just don't want to exist." C-SSRS: endorsed Question 1 (wish to be dead), denied Questions 2-5. No change from admission screening severity.

Plan: Denies plan. Asked: "Have you thought about how you might hurt yourself?" Patient states: "No, I haven't thought about that."
Intent: Denies intent to act. States: "I wouldn't do anything. I just feel this way."
Means: Patient does not have access to means on unit. Belongings searched at admission. Sharps restriction in place. Room safety check completed this shift - no contraband or safety hazards identified.
Timeline: Passive ideation has been present for approximately 3 weeks per patient. No increase in frequency or intensity since admission.
Protective factors: Two children (ages 8 and 5). Patient states: "They're the only reason I'm still here." Also identifies her mother as a support.

Homicidal Ideation: Denies HI. Asked directly: "Are you having thoughts of hurting anyone else?" Patient states: "No, nothing like that."

Hallucinations: Denies auditory, visual, or other hallucinations. No evidence of responding to internal stimuli during interview.

Safety Measures: Observation level Q15min per MD order. Room safety check completed - no contraband, cords secured, sharps accounted for. Unit precautions in place (locked unit, belongings restricted).

Safety Plan: Safety plan reviewed with patient (originally developed at admission with social worker). Patient able to identify warning signs (withdrawal from peers, crying spells, difficulty sleeping), coping strategies (calling her mother, deep breathing, asking to talk to staff), and emergency contacts (mother, crisis line number on card in room). Patient states plan is "helpful" and that she would notify staff if ideation worsens.

Interventions: MD notified of continued passive SI, stable from admission. Current orders maintained. Patient encouraged to participate in group therapy tomorrow. Will reassess next shift and PRN.

Annotations

All 8 SI elements addressed:
Presence, type (passive), plan (denied), intent (denied), means (restricted), timeline (3 weeks, stable), protective factors (children, mother), and interventions (MD notified, orders maintained, encouragement) are all explicitly documented.
Direct quotes throughout:
The patient's exact words are documented for SI screening, plan denial, intent denial, and protective factors. This creates a more defensible record than paraphrasing alone.
C-SSRS score documented:
The standardized screening tool is referenced with the specific questions endorsed and denied, not just a summary score. This allows the next shift to compare directly.
HI and AVH screened and documented:
Even though both are negative, each domain is addressed with the screening question and the patient's response. The absence of findings is documented, not just assumed.
Safety plan specifics, not just "safety plan in place":
The documentation includes the warning signs, coping strategies, and contacts the patient identified - demonstrating that the plan was actually reviewed and that the patient can engage with it meaningfully.

Pro Tips

  • Document SI with all 8 elements every time it's positive: Document all 8 elements in your assessment, even if the ideation remains unchanged from the previous shift. A complete entry each shift creates a longitudinal record that clearly shows the treatment team and any future reviewer the patient's status during your shift. Avoid shortcuts like "SI unchanged," as they require the reader to locate and compare the original entry. If that entry is also incomplete, the gap compounds.
  • Command hallucinations are the most urgent hallucination finding: When a patient reports hearing voices, always ask what the voices say and whether they instruct the patient to do anything. Hearing benign background voices represents a different clinical situation than hearing a voice that commands self-harm. Command hallucinations with violent or self-harm content should trigger immediate provider notification and may necessitate a change in observation level.
  • Every 1:1 Interval Gets Its Own Entry: If you are assigned to 1:1 observation, document at every Q15min interval even if the patient is sleeping. Each entry should reflect what you observed at that specific moment: location, activity, behavior, affect. A single summary note covering multiple hours is not defensible and does not demonstrate continuous monitoring.
  • Replace "no-harm contract" with "safety plan" in your vocabulary: If your unit still uses no-harm contract language, introduce the evidence-based alternative as the nurse. The Stanley & Brown safety plan emphasizes collaboration, specificity, and patient involvement. In contrast, no-harm contracts are clinician-driven, generic, and lack demonstrated efficacy. Using evidence-based language in your charting reflects evidence-based practice.
  • When in doubt, escalate and document that you escalated: If a patient says something that makes you concerned about safety - even if it's ambiguous - document the statement verbatim, notify the provider, and document the notification. "Patient states: 'I don't know how much more of this I can take.' Statement could be interpreted as passive SI. MD notified for evaluation." You are never wrong to escalate a safety concern. You are always wrong to hear one and not document it.

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