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Documentation - Inpatient

Risk of Self-Harm or Suicide

1. When a patient indicates suicidal or self-harming ideation, specifically assess and document the following: plan, means and intent.
2. After assessing a patient who expresses desire or intent to suicide or self-harm, you must notify the patient's nurse and medical team immediately.
3. Document in the patient’s own words, any spoken intentions, threats, or plans to harm him/her self.
4. Document any self-destructive behavior observed by the social worker.
5. Document all actions taken by the social worker to ensure the patient’s safety.
6. Documentation of the notification of the patient's primary team is essential.

For questions regarding patient risk of harm to self, the following resources may be contacted:

• The social worker’s supervisor or the social work administrator on-call (pager 23977).

• In house legal counsel, extension 6-8625, or through the page operator at 6-2241.

• MGH Clinical Policy and Procedure Manual -Suicidal Patients: Care of