Documenting the risk

The importance of documenting risk cannot be understated. From a medico-legal perspective, ‘if you didn’t write it, it didn’t happen’.¹ In situations where there is risk, a certain amount of trial and error, uncertainty and so forth, ‘thinking out loud for the record’² is a useful reminder. Documenting the risk also provides a framework for thought. It has been difficult to develop any one process which successfully incorporates everything to do with risk management into the routine clinical file. There are, however, a few principles of risk management which cannot be ignored. The findings from international inquiries state consistently that the most common failings are those of poor documentation and poor communication.³ There is a medico-legal requirement to document well and clinicians put themselves and their patients at substantial risk when this doesn’t happen.

Risk documentation may vary from just a couple of lines in the notes in simple cases to several pages in more complicated cases; these outline all the static, dynamic and protective factors etc and how these all blend together. In the acute situation, it may well be impossible to adopt a carefully considered approach but in the majority of situations within a mental health setting, risk can be evaluated over a period of time and the process of documentation can be an equally considered process.

Documentation of risk should be concise but contain enough detail as to be useful to a clinician unfamiliar with the patient; for example, those seeing the patient out of hours. The documentation should be useful and not something which is put in the ‘file and forget’ basket. As the document will also be shared with the patient, language the patient can understand should be used (i.e. without psychiatric terminology).

Risk documentation should always include management of the risk and interventions for the dynamic risk factors.

Exactly where risk is documented in the notes will also vary from case to case, depending on the needs of the patient, the degree of risk and the acuity of the situation. How this is achieved seems to vary from one service to another but useful themes that emerge are:

See Figure 11.1 for examples.

Figure 11.1 Examples of how risk is documented

Where mental health services have moved to electronic health records (EHR), this process becomes much easier as risk documentation can automatically be incorporated into the relevant areas of the EHR. Subheading boxes within the risk plan can be completed directly from the assessment. Similarly, subheadings from the risk plan — especially identification of early warning signs and triggers — can be pasted directly into the treatment plan ensuring that the treatment plan covers the management of the risk factors. Updating of risk and treatment plans becomes much easier.

The next five exercises continue the process of getting used to assessing and documenting risk. Consideration of the function of the risk behaviour is now introduced. As described previously, adding this detail provides more contextual information, which helps in the development of treatment interventions. This is very important in illnesses such as borderline personality disorder (BPD) where the risk behaviours may have different meanings for different people but exploring the motivation for the behaviour can be of value in most illnesses.