Ligature and/or Suicide Risk Reduction – Suicide Risk Reassessment

What is required for suicide risk reassessments?

Any examples are for  illustrative purposes only.

Organizations are required to develop and follow written policies and procedures addressing the care of patients identified as at risk for suicide, including guidelines for suicide risk reassessment. Reassessment guidelines should address how often reassessments will occur as well as additional criteria that would trigger a reassessment, for example, a change in patient status, endorsement of suicidal ideation, and/or suicidal or self-harm behaviors or gestures.  An evidence-based process must be used to conduct suicide risk reassessments for individuals who have screened positive for suicidal ideation and were further assessed for suicide risk. At minimum, reassessments must directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.   

The use of an evidence-based assessment tool, in conjunction with clinical evaluation, is an evidenced-based process effective in determining overall risk for suicide. The use of evidence-based tools is strongly encouraged, and it is acceptable for organizations to use language that is more appropriate for their patient population. 

If the organization does not use an evidence-based tool, the following conditions must be met:
  • Organization can demonstrate what evidenced based resource(s) their reassessment is based off
  • The reassessment asks directly about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors
  • How level of risk was determined is clearly documented
The evidence-based process must determine a level of suicide risk (e.g. high, moderate, or low). This overall level of risk must be clearly documented, with clinical justification, as well as the plans to mitigate the risk for suicide.

Additional Resources:
Suicide Risk Reduction Resources
Last updated on February 22, 2021
Manual: Behavioral Health
Chapter: National Patient Safety Goals NPSG

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