What needs documenting on a patient being evaluated for potential suicide? How do you handle a suicidal patient who declines to 'allow' you to contact family member for collateral? Is documenting "pt states they are not suicidal" sufficient?
My vignette: I had a patient come in to the ED for longstanding but undiagnosed AH. He had a complicating history of IVDU. He was in the ED for a while as it took time to get to him, eventually got belligerent and demanded discharge. He reported no suicidal thoughts. Somewhat surprisingly he ended up attempting suicide the following day. Is my chart stating "several month history of AH, but no SI" defensible if the patient had completed his suicide attempt?
Make sure you write "NO SI/HI."
Obviously make sure you don't write "He eventually became belligerent, and I discharged him."
It's not surprising to me that he attempted suicide the following day given the way you phrased your message.
Sometimes it's helpful to say the case out loud to yourself when deciding if safe to discharge. Here goes:
26 year old M with auditory hallucinations. No prior psychiatric history or outpatient psychiatrist. Pt is belligerent and uncooperative.
This seems easy to defend placing a temporary hold to let him chill out and for a psych eval. Remember, he won't be the one suing you when he kills himself. it'll be his family.
What was the CC? Why was he there in the first place?
Would he contract for safety?
Here's a case from MMI which may be helpful:
Would you discharge a patient who refuses to sign a “No Harm Contract”?
Patient hangs self in jail following ED evaluation
HAWKINS v. County of Lincoln, Nebraska
Facts: An adult male slashes his wrist when arrested following a police chase and is taken to the ED for a mental health evaluation prior to booking. His risk factors include depression, bipolar disorder, legal problems, impulsivity, prior suicide attempt, recently failed relationship, unemployment and PTSD. His wounds are superficial and require no sutures. He is evaluated by a social worker. A psychiatrist is consulted by phone and believes him to be safe to go to jail. When presented with his Discharge Instructions and a No Harm Contract, he refuses to sign the latter, yet is discharged -
only 25 minutes after arrival. There is no documentation of any discussion with the patient or amongst the staff about his refusal to sign. Two days later he hangs himself in his cell.
Plaintiff: My brother’s life was in danger. He was telling you he would kill himself. You knew that or you wouldn’t have asked him to sign the No Harm Contract. He told you that he would only sign if he were released from custody, and that was not an option. You should have admitted him. All you did was call the jail and tell the jailer to put him “naked in a bare cell.” A jail is for incarceration, not suicide prevention.
Defense: He was safe to go to jail. We evaluated your brother properly. In fact we did a triage evaluation, vital signs, registration, financial agreement, nursing assessment, an 11-item "ED Mental Health Evaluation,” a complete history (including HPI, PFSH, and review of 8 systems), exam of 10 systems including neuro and psych, dressing of wounds, telephone conversations with a psychiatrist and Lincoln County jailer, complete medical decision making and treatment plan, DC instructions, a "No Harm Contract" and dictated a report prior to transfer -
all in 25 minutes.
Result: Settlement for undisclosed amount.
Takeaway: When evaluating suicidal patients, take and document a complete history, then pay attention to what you’ve found. Most such patients in the typical ED can be safely discharged. Some with a host of risk factors deserve more than a 25 minute evaluation - especially when they then refuse to sign a “No Harm Contract.” Even if they do sign,
the form is not what protects you but the process, discussion and documentation that accompanies it. Reference ->
