title: Suicide Risk Assessment by Residents: Deficiencies of Documentation.
abstract: OBJECTIVE
  The authors sought to assess the documentation of suicide risk assessments performed by psychiatry residents in a psychiatric emergency service (PES) and to identify differences in documentation between previously used paper charts and a new electronic medical record (EMR) system based on the Columbia Suicide Severity Rating Scale (C-SSRS)-risk assessment version.
  
  
  METHODS
  This study is a retrospective chart review of psychiatric evaluations performed by psychiatry residents during a 1-year period in the PES of a large, urban, academic medical center. The sample was selected by a systematic random sampling technique from a total of 3931 evaluations performed on adult patients during the study period. The suicide risk assessments were evaluated using data regarding demographics, process indicators identified from the C-SSRS, and diagnoses.
  
  
  RESULTS
  A total of 300 charts were reviewed. Only 91% of the evaluations contained documentation of suicidal ideations (either admitted or denied); 5 other variables were documented in more than 50% of the evaluations: treatment status (95.3%), presence/absence of previous suicide attempts (84.6%), recent event-denies (56%), history of recent negative events (55%), and suicidal behavior-denies (53%). Additionally, 2 risk factors and 3 protective factors were documented in over 25% of the evaluations.
  
  
  CONCLUSIONS
  Documentation was deficient in multiple areas, with even the presence/absence of suicidal ideations not being documented in all evaluations. Use of an EMR with built-in "clickable" options selectively improved documentation especially regarding risk and protective factors adapted from the C-SSRS. Emphasis on documentation of assessments is paramount while training residents in suicide risk assessment.
authors.affiliation: Maimonides Medical Center, Brooklyn, NY, USA.
authors.forename: Yasas
authors.initials: Y
authors.lastname: Tanguturi
authors.affiliation: Maimonides Medical Center, Brooklyn, NY, USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Bodic
authors.affiliation: Maimonides Medical Center, Brooklyn, NY, USA.
authors.forename: Abraham
authors.initials: A
authors.lastname: Taub
authors.affiliation: Maimonides Medical Center, Brooklyn, NY, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Homel
authors.affiliation: Maimonides Medical Center, Brooklyn, NY, USA. tjacob@maimonidesmed.org.
authors.forename: Theresa
authors.identifier: http://orcid.org/0000-0002-2654-5071
authors.initials: T
authors.lastname: Jacob
mesh_terms: D000328:Adult; D004637:Emergency Services, Psychiatric / Q000379:methods*; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008499:Medical Records / Q000706:statistics & numerical data*; D011569:Psychiatric Status Rating Scales; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D059020:Suicidal Ideation; D013406:Suicide, Attempted / Q000706:statistics & numerical data*; D014481:United States
keywords: Emergency psychiatry; Residents; Suicide