Risk assessment- scenario: Watch this consultation. Imagine you need to document the discuss and the risk assessment that the professional made. What format will you use to structure it? How might you word it?
A suggestion for documentation-
Ideas, intent, method considerations and plan:
This lady is reporting suicidal ideation. She initially describes feeling calm and resolute about this plan. She states not feeling afraid to end her life. She reports having intent to die. She has considered the method (overdose of tablets) and is preparing to make plans by leaving documents for her husband. She has stated that she thinks her friends and family would be better off without her.
She has however informed her therapist of this plan, knowing that she may then be prevented from following through on her expressed plan. She is aware of this and understands what the next steps will likely be. This suggests some inconsistency in her suicidal intent and some ambivalence about what she truly wants to happen. She later admits that she is unsure, when challenged. She agreed to admit herself voluntarily to hospital, after a conversation with a therapist.
By the end, she agreed to take responsibility for health. She acknowledged hope that she could feel better and showed a degree of future orientation.
Triggers (Predisposing, precipitating and perpetuating factors):
She discussed some of the triggers to this decision, such has her recent depressive symptoms. Presumably these have been covered more in previous contact.
She discussed her protective factor of her family. She also has a husband and friends and has involved them in previous care plans. She has a good relationship with her therapist and has presented in crisis to him.
Remember to keep calm when talking with distressed patients, although always empathise and try and understand the patient’s point of view. Often empathy and validation is key. Don’t be afraid to challenge. In the end, this is an example of how effective engagement with a patient can be. And how he was able to preserve the therapeutic relationship.