Risk assessment: focus on documentation

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Chapter 11 Risk assessment: focus on documentation

Keep the language simple.

This chapter builds on the previous chapters and begins to add a focus on the function of the risk behaviour. It is useful at this stage to focus again on aspects of documentation before revisiting the risk tool.

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:

• risk assessments, no matter how brief, are copied onto a risk form and put into a separate compartment in the file

• risk documentation is written on different coloured paper

• all risk documentation is copied to the mental health crisis team

• as more information becomes available, this should be added to the risk plan incrementally

• if risk issues are incorporated into the assessment, these are given headings and put in a box.

See Figure 11.1 for examples.

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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.

BOX 11.1 RISK DOCUMENTATION — THE RISK PLAN

Practice points: what a risk plan does

• It documents that risk has been considered and assessed.

• It puts the risk into the context of the current illness (mental state factors and patterns).

• It allows for consideration of situational factors (and patterns).

• It documents protective factors.

• It lays the foundation for risk management

• When combined with the treatment plan, dynamic risk factors and signs of relapse will also be managed.

• It does not usually state a definitive plan of action but makes recommendations. Treatment decisions in the acute situation are left to the clinician on the spot.

• Documenting the risk in a risk plan becomes a component of treatment for the underlying illness.

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.

The only part missing after these exercises will be the introduction of interventions for the risk factors, early warning signs and triggers. When necessary, use the list of risk factors in Tables 9.1 and 9.2 (pages 80–81 and 84–85). Remember, it is more useful for your colleagues if you write in a narrative form but don’t get carried away by writing a thesis! The idea is to be brief and succinct. A test of the usefulness of your documentation is to show it to a colleague and ask them if it makes sense. As you get used to completing these examples, you will begin to notice that they also help you highlight areas where the treatment will need to focus. To an extent, documenting the risk in the form of a plan will direct some aspects of treatment.

Don’t worry about whether you get the information in the correct box. As long as you get the information down on paper, your colleagues will be able to make use of it. You may also find that the same information is documented twice. Once again, it’s better that it’s down on paper than not at all.

Exercise 1 — Depression and post-traumatic stress disorder (PTSD)

David, 42 years old, has been seeing you and the consultant psychiatrist for 3 months for a depressive illness which has not responded well to a mixture of cognitive behaviour therapy (CBT) and antidepressants. Both you and the psychiatrist have felt that there is something missing from the history but despite gentle questioning, David has not told you anything more. During a routine case management session, he begins to tell you a story of being sexually abused by a male teacher when he was 14 years old during a school camp. This new information has been prompted by him reading an article in today’s newspaper about a similar event. David becomes very tearful and angry and at one stage during the session; you wonder if he dissociates (see glossary). Towards the end of the session, David says that he knows where the teacher lives. At the end of the session, David is feeling very raw and you arrange to see him later on in the week and tell him that you will talk to the psychiatrist about this new information. Over the next few weeks, David develops flashbacks, poor sleep and greater anxiety. His depression is possibly worse and he is increasingly preoccupied with the idea of vengeance. He says that he would certainly not kill himself until justice has been served on the man who abused him. He is frightened by the intensity of his violent feelings. He has thought of the idea of attacking the teacher but has not taken these thoughts further. He says that remorse would overwhelm him.

David lives on his own and has few friends. He does not wish you to talk to his friends. He says that he has not been violent in the past and he does not drink or use drugs. He says that he does not want to kill himself but wonders how long he can endure this torment. He has made no plans to kill himself. From the information given, complete the risk documentation form for David. Figure 11.2 contains a risk documentation template. The completed form appears in Appendix 3.

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Figure 11.2 Risk assessment and management template

Comment

This example is not uncommon in routine clinical practice. The risks are of both suicide and violence and the two are interlinked. What the clinicians have not done here is explore the risks in sufficient detail. They will need to ask the patient what means he might use for suicide or violence, whether he has planned it, and what might happen if he met the teacher on the street. They will need to consider impulsivity and consider what may tip him over into a violent or suicidal act. Are there any critical risk factors and signature risk signs which may be of importance? No early warning signs and triggers have been identified yet. The clinicians will need to meet to discuss this in some detail with David. However, it is important to start documenting the risk even if more details will be forthcoming later. The process of documenting the risk on a form often highlights areas of the history and current thinking that need clarification. The documentation on motivation for the risk behaviour carries vital information for a colleague caring for David after hours.

As can be imagined, the successful treatment of the underlying depression and PTSD will resolve the risks.

Example 2 — child and family example

Mike is an 8-year-old boy who has been referred to your child and family clinic because of secondary enuresis (bed wetting) and school phobia. This seemed to develop after the separation of his parents 6 months ago, although his brother and sister have coped well with the separation. He has been staying predominantly with his mother although he has each weekend with his father. His father’s parents have also been helping out during this difficult time. When you see Mike on his own, he tells you in a somewhat shy, hesitant voice that everything is all right at home but he does wish that his parents would get back together again. He cannot account for his enuresis or school refusal and simply says that he does not like school anymore. Later on, you have a meeting with Mike and both his parents. His parents express appropriate concern but you begin to notice that Mike is much more hesitant and cautious in his interactions with his mother. At the end of the interview, you put your hand over Mike’s shoulder to give him a friendly pat and he winces. Mike initially tells you that he fell over in the playground but after arranging a physical examination by his GP, the story begins to unfold that his mother has ‘needed to contain him’ at times when he puts up a fight about going to school.

From the information given, complete the risk documentation form for Mike. Refer to Figure 11.2 for a risk documentation template. The completed form and discussion appear in Appendix 3.

Exercise 3 — an example of using the model for exploring relapse prevention

Brian is a 45-year-old man with a diagnosis of schizoaffective disorder. His history is of several manic episodes complicated by auditory hallucinations, grandiose delusions and persecutory ideation. Not infrequently, the psychotic symptoms continue after the mood component has settled. The auditory hallucinations are variable in their content. Sometimes they tell him he is wonderful and can do anything he wants and at other times they have a paranoid flavour to them and tell him that he is being watched.

Brian has very little insight into his illness and prefers not to take his prophylactic medication all the time. He takes it more often than not though, as he says it helps him sleep. When manic, Brian is overactive, grandiose and disinhibited. The last time he was ill, he ‘borrowed’ a race horse from the local stables and rode it bareback to his home. Brian has not been violent previously but can be impulsive and at times verbally aggressive. He says that he doesn’t really have an illness but his long suffering wife says that she can pick up the early signs of a relapse from his behaviour. She says that apart from the sleep disturbance, she ‘knows’ when he is getting ill.

From the information given, complete the risk documentation form for Brian. Refer to Figure 11.2 for a risk documentation template. The completed form and discussion appear in Appendix 3.

Exercise 4 — alcohol and drug example

Rachel is 34 years old and married to Jeremy. They have two children aged 8 and 4. Rachel has been alcohol dependent for nearly 6 years and also suffers from generalised anxiety disorder and occasional panic disorder. In her history, she was brought up in a loving, caring family who remain very supportive of her. When she was 19, Rachel was date raped but says that she has got over this. She has been treated in the local alcohol and drug service and currently takes naltrexone and paroxetine but there are substantial concerns about her compliance with these medications.

Four months ago, Rachel had a major relapse into alcohol use and, after smashing the family car and falling down the stairs, she voluntarily admitted herself to a residential program. For the first 6 weeks of the 8-week program she participated little but in the last 2 weeks, she began to participate and acknowledged that she no longer loved her husband and that the date rape caused her to avoid sex and also gave her nightmares. Since returning from her residential treatment, Rachel has again relapsed and says that she will not go back to residential treatment again. She says that she will be able to sort things out in her counselling. She has not told her husband about her feelings about the marriage. Her liver function tests are surprisingly normal. Although you have advised her not to drive, her husband tells you that she is still driving her children to school.

From the information given, complete the risk documentation form for Rachel. Refer to Figure 11.2 for a risk documentation template. The completed form and discussion appear in Appendix 3.

BOX 11.2 CLINICAL TIP

Alcohol is a major factor for both violence and suicide and other risks. Other substances, especially stimulants such as amphetamines, also create problems. It is current use which creates major difficulties at the time of assessment. Usually the difficulty is intoxication but a patient experiencing acute withdrawals can also have a lowered threshold for impulsive actions.

• A general rule of thumb if a patient is intoxicated at the time of assessment is to assume that a thorough mental state examination cannot be completed until the patient is no longer under the acute influence of the drug.

• Intoxication may well mean that the patient needs to be contained in a place of safety until sober.

• Policies and memoranda of understanding should be in place between mental health services, Emergency Departments (EDs) and police to manage this common occurrence.

• Clinicians should make a point of getting a collateral history from friends and family at these times.

Exercise 5 — opioid substitution example

Melanie is 35 years old and is a patient on your opioid substitution program and is prescribed methadone. She is hepatitis C positive but is otherwise well. She has a long-standing needle fixation and tends to inject her Sunday dose, which she picks up on Saturdays because her local pharmacy is closed on Sundays. The next nearest pharmacy, which is open on Sundays, is 25 km away. Melanie survives on a sickness benefit and says that she cannot get to the other pharmacy on Sundays. Melanie has diverted her weekday dose from time to time in order to inject. She is currently in a de facto relationship with Greg. He is on the waiting list for the opioid substitution program but the current wait is around 6 months. He has been assessed for the program and tells you that he is using morphine 30–60 mg every 2–3 days.

From the information given, complete the risk documentation form for Melanie. Refer to Figure 11.2 for a risk documentation template. The completed form and discussion appear in Appendix 3.

Notes

1 Gutheil T.G. Paranoia and progress notes: a guide to forensically informed psychiatric record keeping. Hospital and Community Psychiatry. 1980;31(7):479–482.

2 Gutheil, above, n 1.

3 Maden A. Risk assessment in psychiatry. British Journal Hospital Medicine. 1996;56:78–82.

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