By Amy Niemas, RN-BC, BSN, MSW, Clinical Content Director · Psychiatric Registered Nurse

Last updated: October 13, 2026

What SI/HI/AVH Means and How to Chart It (Nursing Guide)

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Why This Matters

Regulatory bodies: Joint Commission National Performance Goal 8 (hospitals, from January 2026), Joint Commission National Patient Safety Goal 15.01.01 (behavioral health care organizations), CMS Conditions of Participation, State Mental Health Codes

SI, HI, and AVH are asked of every psych patient, on every shift, because they are the findings most closely tied to immediate safety. The Joint Commission expects more than just the question, however. Since January 1, 2026, hospitals follow National Performance Goal 8 ("The hospital reduces the risk for suicide"), which replaced National Patient Safety Goal 15.01.01 (the Joint Commission's earlier suicide risk standard) for hospitals. Behavioral health care organizations still follow National Patient Safety Goal 15.01.01. The requirements match: screen with a validated tool, and after a positive screen, use an evidence-based assessment that directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. Element of Performance 4 requires documenting the patient's overall level of risk for suicide and the plan to reduce it. The Joint Commission ties these requirements to the patient right to care in a safe setting in the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. A denial is not the same as low risk. A 2019 review that pooled 71 studies found that earlier suicidal ideation identified only 41% of the people who later died by suicide: most had not reported it. A review of 13 studies found no evidence that asking about suicide causes suicidal ideation, and asking may reduce it. Writing in Psychiatric Times, the psychiatrists Thomas Gutheil and Robert Simon said of the "no SI/HI" documentation that "this handful of letters does not represent an adequate suicide or homicide risk assessment of the patient." An entry with the patient's words, the time, what you saw, and what you did shows that the assessment happened. This guide covers documentation. It does not replace your facility's suicide prevention policy or your clinical judgment; it is general information, not legal advice.
  1. National Performance Goals, Effective January 2026 for the Hospital Program (Goal 8, NPG.08.01.01) — The Joint Commission (2025)
  2. R3 Report Issue 18: National Patient Safety Goal for Suicide Prevention (NPSG 15.01.01) — The Joint Commission, November 2018, updated December 2025 (2018)
  3. Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value — McHugh CM, Corderoy A, Ryan CJ, Hickie IB, Large MM. BJPsych Open. 2019;5(2):e18 (2019)
  4. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? — Dazzi T, Gribble R, Wessely S, Fear NT. Psychol Med. 2014;44(16):3361-3363 (2014)
  5. Empty Words in Psychiatric Records: Where Has Clinical Narrative Gone? — Gutheil TG, Simon RI. Psychiatric Times, December 2011 (2011)
  6. Suicidal Ideation — Rizvi A, Harmer B, Saadabadi A. StatPearls, NCBI Bookshelf (2024)
  7. Mental Status Examination — Voss RM, Das JM. StatPearls, NCBI Bookshelf (2024)
  8. Auditory Hallucinations — Thakur T, Gupta V. StatPearls, NCBI Bookshelf (2023)
  9. Psychosis — Calabrese J, Al Khalili Y. StatPearls, NCBI Bookshelf (2023)
  10. The DSM-5 diagnosis of nonsuicidal self-injury disorder: a review of the empirical literature — Zetterqvist M. Child Adolesc Psychiatry Ment Health. 2015;9:31 (2015)
  11. Mental Health Professionals' Duty to Warn — National Conference of State Legislatures (2022)
  12. 988 Suicide and Crisis Lifeline — SAMHSA / Vibrant Emotional Health (2024)

What SI, HI, AVH, and NSSI Mean

These four abbreviations cover the safety questions asked of every psychiatric patient, on every shift, and they are part of the safety assessment in psychiatric nursing charting. You will see them together in almost every psych nursing note, most often as "denies SI/HI/AVH."

SI: Suicidal Ideation

Suicidal ideation (SI) means thoughts of killing yourself. It runs on a spectrum. At one end is a general wish to be dead with no method, plan, or intent, often called passive SI: "I wish I could go to sleep and not wake up." At the other end is active SI, with thoughts of how, a plan, or intent to act: "I have been thinking about taking all my pills." Chart which one, in the patient's words. The Columbia Suicide Severity Rating Scale (C-SSRS) walks this spectrum one question at a time.

HI: Homicidal Ideation

Homicidal ideation (HI) means thoughts of killing or seriously harming another person. Like SI, it ranges from a passive wish ("I wish he were dead") to active thoughts of harming someone, with or without a plan or intent. The detail that changes the response most is the target: if the patient names a specific person, further interventions are needed. (This will be discussed in detail in a later section.)

AVH: Auditory or Visual Hallucinations

Hallucinations are perceptions with nothing outside the person causing them: hearing voices or sounds (auditory) or seeing things (visual) that other people do not. Some facilities chart them separately as AH (auditory hallucinations) and VH (visual hallucinations), and hallucinations can involve touch, smell, or taste too. Command hallucinations are voices that tell the patient to do something. They carry the most safety weight and require further interventions when the command is to hurt themselves or someone else.

NSSI: Non-Suicidal Self-Injury

Non-suicidal self-injury (NSSI) is inflicting deliberate damage to your own body, such as cutting, burning, or hitting, but without the intent to die. Intent is what separates it from a suicide attempt. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists NSSI disorder as a condition that needs further study, not an established diagnosis. Remember to chart the behavior and the patient's stated intent, so that the distinction is clear.

Reading "Denies SI/HI/AVH" in a Note

If you are reading someone else's note, "denies SI/HI/AVH" means the patient said no when asked about thoughts of suicide, thoughts of harming others, and hallucinations. It is a routine line. What it does not tell you is how the question was asked or what the nurse saw. That is what the rest of this guide covers. Whether you can write these abbreviations at all depends on your facility's approved abbreviation list. SI, HI, and AVH are common, but they are not universal. If they are not on your facility's list, spell them out completely.

How to Chart a Denial of SI/HI/AVH

A denial is still an assessment finding, and it needs the same documentation as any other finding. A complete denial entry includes: - The question you asked, in direct language ("Are you having any thoughts of killing yourself?"). - The patient's answer, quoted directly when their words add clarity or meaningful descriptions. - What you observed and whether it fits the denial: affect, behavior, eye contact, and whether the patient appears to be responding to internal stimuli (talking to, looking at, or reacting to something no one else can see or hear). - The safety check and the contingency: the patient states they feel safe in the hospital and agrees to alert staff if thoughts or feelings change. You can also add "The patient contracts for safety" if you have specifically discussed a safety plan or no-harm contract with them. - The current observation level (the standard is checks every 15 minutes) and the plan. The safety check and contingency record what the patient told you and what the patient agreed to do if things change. They are not a no-harm contract, unless you specifically discuss and document one as above. Charting example: "0900: Asked patient directly about thoughts of suicide, thoughts of harming others, and hallucinations. Patient denies suicidal ideation, plan, or intent. Denies homicidal ideation. Denies auditory or visual hallucinations. Calm, good eye contact, affect congruent with stated mood of 'better today.' Not observed responding to internal stimuli. States they feel safe in the hospital, and agrees to alert staff if thoughts or feelings change. Will continue to monitor with q15-minute checks for safety." Importantly, if at any time a patient endorses SI, you must document the interventions done to address this. Documenting positive SI without intervention and follow-up is a tremendous safety risk and also a red flag in your charting.

How to Chart When a Patient Endorses SI

The most important part of a positive entry is what you do after a positive SI response. Chart the finding, the patient's words, and your response in the order they happened, with times.

A positive SI entry includes: - Type: passive or active, in the patient's words. - Plan: whether the patient has thought about how, and the method they describe. - Intent: whether the patient intends to act. Plan and intent are separate; chart each one. - Access to means: what the patient says they have access to, and what has been secured. - Timeline, if the patient gives one. - Protective factors: what the patient says is keeping them safe. - The immediate safety measures you started, with the time initiated. - Provider notification: who, how, when, and any orders that followed. - When you will reassess. When a patient endorses active SI with an intent or plan, start the safety measures within nursing scope immediately (such as 1:1 observation per facility policy, and ensuring the environment remains safe and free of harmful items), then notify the provider. Do not wait for a call back to keep the patient safe. Your facility's suicide prevention policy sets the observation level and who completes the full suicide risk assessment; in many hospitals that is a provider, social worker, or nurse practitioner. The safety assessment charting guide covers observation levels and 1:1 documentation in depth, and a positive finding belongs in the Assessment part of your SBAR handoff. Charting example: "1400: Patient approached staff and stated, 'I keep thinking about hanging myself. I do not know if I can stop myself tonight.' Endorses active suicidal ideation with a method (hanging) and some intent. Denies a specific time or place. Identifies their sister as a reason to keep living. 1:1 sitter initiated at 1402. Provider notified by phone at 1410 with the patient's statement and the safety measures in place. Orders received for continued 1:1 observation and a same-day suicide risk assessment. Will reassess at 1500 and as needed. Will monitor with 1:1 staffing and also with q15-minute unit safety checks."

How to Chart When a Patient Endorses HI

Homicidal ideation follows the same structure as SI: the patient's words, the target, the plan, intent, access to means, and nursing interventions. The target is what drives the response. A threat against a named, identifiable person can trigger a duty to warn or protect that person, and those laws differ by state. Some states require disclosure, some permit it, and a few have no such duty. You are not expected to decide the legal question at the bedside. Report the statement to the provider and the charge nurse right away, follow your facility's policy, and chart who you told and when. Charting example: "2030: Patient stated, 'When I get out of here I am going to kill my neighbor. He knows what he did.' Endorses homicidal ideation toward a specific, named neighbor. Denies a plan when asked, stating, 'I have not figured that out yet.' States there are no weapons at home. Provider and charge nurse notified at 2035 with the patient's exact statement. Denies suicidal ideation, plan, or intent, and denies hallucinations. States they feel safe in the hospital. Agrees to alert staff if thoughts or feelings change. Social work consult requested per facility policy for duty-to-warn review. Will continue to monitor with q15-minute checks for safety. Will reassess at 2130."

How to Chart Hallucinations, Including Command Hallucinations

For any reported hallucination, chart the type (auditory, visual, or another sense), the content in the patient's words, how often it happens, and how the patient is responding to it. For voices, add how many there are and whether the patient recognizes them. For command hallucinations, ask what the voices tell the patient to do, whether the patient feels able to resist, and whether they have acted on commands before. A command to hurt themselves or someone else needs the same immediate safety response and provider notification as active SI or HI. Visual hallucinations can have a medical cause. They can be seen in severe alcohol withdrawal, advanced dementia, or an adverse response to medication, for example. Auditory hallucinations can have these causes too, including dementia, substance use, and medication side effects. Report new visual hallucinations to the provider rather than assuming they are psychiatric in nature. Chart what you observe even when the patient denies hallucinations. If a patient denies AVH but you see them talking to an empty corner, chart both the denial and the observation. That mismatch is a finding. The thought and behavior charting guide covers how to describe these behaviors without interpreting them. Charting example: "1100: Patient reports hearing one unfamiliar male voice 'most of the day' that says, 'You do not deserve to eat.' States the voice has never told them to hurt themselves or anyone else, and they are able to ignore it. Denies visual hallucinations. Observed pausing mid-sentence and looking toward the doorway twice during the conversation. Denies suicidal and homicidal ideation. States they feel safe in the hospital. Agrees to alert staff if thoughts or feelings change. Provider aware of ongoing auditory hallucinations. No new orders. Will continue to monitor with q15-minute checks for safety."

NSSI (Non-Suicidal Self-Injury): How It Differs From SI and How to Chart It

The difference between NSSI and a suicide attempt is the patient's intent, so ask directly; for example, "When you cut yourself, were you trying to end your life?" A history of self-injury is linked to later suicide attempts. A history of NSSI does not replace SI assessment, as a patient can have both. Make sure you address both of them. For NSSI, chart the method, the location on the body, when it happened, why the patient says they do it (e.g., is it a coping mechanism?), and any applicable wound assessment and care. Describe the specific behavior, and leave out labels such as "attention seeking" or "manipulative," which are interpretations, not observations. Charting example: "0730: Three superficial linear cuts noted on left forearm, each about 2 cm, edges approximated, no active bleeding. Patient states they used a piece of paper folded into sharp edges at about 0600 and that it 'takes the pressure off.' States, 'I was not trying to kill myself.' Denies suicidal ideation, plan, or intent. States they feel safe in the hospital. Agrees to alert staff if thoughts or feelings change. Wounds cleaned and covered with a dry dressing. Provider notified at 0745. Wound care orders received. Will reassess at 0930. Will continue to monitor with q15-minute checks for safety."

SI/HI/AVH Documentation in NurseChartingPro

In NurseChartingPro, these findings are part of the psych Safety Assessment category. Mark the suicidal ideation flag when the patient endorses SI. For homicidal ideation, record whether a target is identified, the interventions, and the provider orders. For hallucinations, record the type, the description in the patient's words, the interventions, and the provider orders. Use the notes for what the fields do not hold on their own: the question you asked, the patient's exact words, what you observed, and the times of each action.

Common Mistakes

Charting "denies SI/HI/AVH" with nothing else

Weak: Pt denies SI/HI/AVH.
Strong: Asked patient directly about thoughts of suicide, thoughts of harming others, and hallucinations. Patient denies suicidal ideation, plan, or intent. Denies homicidal ideation. Denies auditory or visual hallucinations, and is not observed to be responding to internal stimuli. Affect bright, mood positive. Attended group this morning, and has been interacting appropriately with other patients and staff. States they feel safe in the hospital. Agrees to alert staff if thoughts or feelings change. Will continue to monitor with q15-minute checks for safety.

The short version does not show what was asked, how, or what you observed. When the same line appears shift after shift, a reviewer cannot tell whether anyone asked at all. Write the denial fresh each time, with what you observed this shift.

Charting positive SI with plan and intent, without the response

Weak: Patient endorses SI with plan and with intent. Will notify provider.
Strong: At 1510, patient endorses active SI with plan; states, "I want to kill myself and I will find a way to do it here." 1:1 observation initiated at 1515. Provider notified at 1520. Orders received for continuous 1:1 observation. Will reassess at 1615. Will monitor with 1:1 staffing and also with q15-minute unit safety checks.

"Will notify provider" does not include the initiation of the 1:1 observation. A positive finding with no documented intervention and follow-up is a major safety risk and a significant red flag in the chart.

Charting "denies AVH" when the behavior says otherwise

Weak: Denies AVH.
Strong: Denies auditory or visual hallucinations when asked. Observed at 2200 and 2230 sitting alone in room, whispering and pausing as if listening, then laughing. When asked, states, "I am just thinking." Provider notified of observed behavior. Will continue to monitor with q15-minute checks for safety and more often as needed.

A denial and an observation can disagree. Chart both. Leaving out what you saw indicates that the patient was free of hallucinations when your own observations suggest otherwise.

Calling NSSI a suicide attempt, or dismissing it

Weak: Patient came to nurses' station and showed his cut wrists, in an apparent suicide attempt, with attention-seeking behavior.
Strong: Patient came to the nurses' station at 2015 and asked to speak with this RN, then showed his right wrist with two superficial cuts visible. No active bleeding. Patient states, "I just cut to calm down. I did not want to die." Firmly denies suicidal ideation, plan, or intent. Cuts cleansed and bandages applied. Patient states he feels safe in the hospital and agrees to alert staff if thoughts or feelings change. Provider notified at 2030, no new orders given. Will continue to monitor with q15-minute checks for safety and more often if needed.

Whether an act was a suicide attempt depends on the patient's intent, so ask and quote it directly. "Attention seeking" is an interpretation, not an observation, and it can lead the next reader to take real risk less seriously.

Charting HI without the target or who was told

Weak: Pt endorses HI. Provider aware.
Strong: At 1815, patient endorses HI towards his brother, and states, "I am going to hurt my brother when I see him." Denies a specific plan. Provider notified at 1830 with the patient's exact statement. No new orders received. Charge nurse also aware. Social work consult requested per facility policy. Will continue to monitor with q15-minute checks for safety.

Whether a specific person is named changes what happens next, including a possible duty to warn under state law. Chart the target, the patient's words, and every person you notified, with the time.

Pro Tips

  • Read the screening tool word for word: If your facility uses a validated screener, such as the C-SSRS or the Ask Suicide-Screening Questions (ASQ), read each item exactly as written. The Joint Commission says not to change the wording of a validated tool, because even small changes can affect its accuracy.
  • Ask directly, using the word suicide: Ask, "Are you having any thoughts of killing yourself?" rather than "Are you having any dark thoughts?" Softer wording asks a different question, and a patient can answer the softer question honestly and still leave out what you need to know. Asking directly has not been shown to cause or worsen suicidal thoughts.
  • Write the denial fresh every shift: Do not copy a denial forward from the last shift. If the entry reads the same every time, the next reader cannot tell whether you asked. What you observed this shift is what shows the assessment happened.
  • Ask what is keeping them safe (protective factors): Ask, "What has kept you going so far?" and quote the answer. "Identifies their daughter and their job as reasons to stay safe" tells the provider and the next nurse something that a denial never could, and it also shapes the safety plan and the discharge plan.

Step by Step

  1. Ask directly: Ask about thoughts of suicide, thoughts of harming others, and hallucinations in plain words. If your facility uses a validated screening tool, read its items exactly as written.
  2. Chart the answer in the patient's words: Use the patient's words, in quotations, for any positive finding, and also for a denial when the words add something. For SI and HI, chart plan, intent, and access to means separately.
  3. Chart what you observed: Record affect, behavior, and whether the patient appears to be responding to internal stimuli. If what you see does not fit what the patient says, chart both.
  4. For a denial, chart the safety check and the contingency: Record that the patient states they feel safe in the hospital and agrees to alert staff if thoughts or feelings change, plus the current observation level.
  5. For a positive finding, act, then notify: Start the safety measures within nursing scope, such as implementing 1:1 staffing immediately, then notify the provider. Chart each action, who you notified, the orders received, and the times.
  6. Set the reassessment time: Chart when you will reassess, and make sure you follow up at that time.

Frequently Asked Questions

What does SI/HI/AVH mean in nursing?
SI/HI/AVH stands for suicidal ideation, homicidal ideation, and auditory and/or visual hallucinations. "Patient denies SI/HI/AVH" means the patient said no when asked about thoughts of suicide, thoughts of harming others, and hallucinations. It is a routine entry in psychiatric nursing notes, but stronger charting addresses each area specifically, not all as one line.
What does NSSI stand for?
NSSI stands for non-suicidal self-injury: deliberately harming your own body, such as cutting or burning, but without intent to die. It is charted separately from a suicide attempt because the intent is different. Ask about both.
What is the difference between passive and active SI?
Passive SI is a wish to be dead without a method, plan, or intent (such as, "I wish I would not wake up"). Active SI includes thoughts of how to do it, a plan, and/or intent to act. Chart which one, in the patient's words, and chart plan and intent separately.
Is "denies SI/HI/AVH" enough documentation?
No, "denies SI/HI/AVH" on its own is not enough documentation. It only shows that questions were asked. A complete entry adds the question you asked, the patient's words, what you observed, the safety check (e.g., the patient states they feel safe in the hospital), the contingency (e.g., the patient agrees to alert staff if thoughts or feelings change), and the observation level (e.g., q15-minute checks for safety).
Does asking about suicide put the idea in a patient's head?
No, asking about suicide does not put the idea in a patient's head. A review of 13 studies found no evidence that asking about suicide causes suicidal ideation; in fact, asking may actually reduce it, because it allows the person to identify it and get support. Ask directly, using the word suicide or the words "killing yourself."
How do I chart that a patient has no hallucinations?
Chart what you asked and what you saw: "Denies auditory and/or visual hallucinations. Not observed responding to internal stimuli." If the patient denies hallucinations but you see behavior that suggests them, such as talking to no one or pausing as if listening, chart both their denial and what you observed.
What are command hallucinations, and how do I chart them?
Command hallucinations are voices that tell the patient to do something. Chart what the voices say in the patient's words, whether the patient feels able to resist, and whether they have acted on commands before. A command to hurt themselves or someone else needs an immediate safety response and provider notification.
Can a nurse work on a safety plan with a patient who has active SI?
Nurses often work on a written safety plan with the patient, and that work belongs in the chart. For a patient with active SI, the safety plan does not replace the immediate safety measures, the provider notification, or the full suicide risk assessment your facility requires. Check your facility's policy for who completes the safety plan.
Do nurses have a duty to warn when a patient has HI?
Whether a duty to warn applies depends on state law, because duty-to-warn laws are set by each state. Some require disclosure, some permit it, and a few have no such duty. At the bedside, report the patient's statement and the target to the provider and the charge nurse right away, follow your facility's policy, and chart who you notified and when.
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