Progress note efficiency: How clinicians can write faster and stay compliant
Summary
Learn how risk assessment documentation helps you record client risk factors, protective factors, clinical observations, and next steps to support safe, effective care.
Understand how clinical risk management guides you in assessing, managing, and documenting risks related to suicide, self-harm, harm to others, abuse, and neglect.
Identify key risk factors and warning signs, use validated assessment tools, and determine appropriate interventions based on clinical judgment.
Improve your EHR documentation by including client statements, safety plans, referrals, follow-up plans, and consultations.
Clinical risk management is a foundational element of our role. Still, for newer clinicians, interns, and others starting out, it can be overwhelming to know what must be documented, how to assess thoroughly, and how to handle emergencies.
This article provides an overview of risk assessment documentation, including risk criteria and what to include in your electronic health record (EHR).
What is clinical risk management?
In a client context, clinical risk management involves assessing, managing, and documenting each client's risk. More specifically, it involves:
Assessing for risk: Clients may be assessed for increased risk of harming themselves through suicide, or non-suicidal self-injurious behavior (NSSIB), hurting others, or the potential to be a victim of abuse or neglect.
Managing risk: Based on their assessment and clinical judgment, clinicians determine the level of intervention required to mitigate or control risk, such as implementing a safety plan, and include this in their treatment planning.
Documenting risk: As part of clinical risk management, risk assessment documentation involves recording these activities, relevant observations, and clinical judgment in the client’s record quickly and accurately.
The goal of clinical risk management is to ensure client safety and protection for the client and clinician.
What are risk factors?
Risk factors include:
Individual risk factors: A previous suicide attempt, history of depression and mental health conditions, legal issues, physical health conditions, financial problems, work-based stress, substance use, trauma, abuse, adverse childhood experiences, violence and victimization, impulsive or aggressive tendencies, domestic violence, grief, and a sense of hopelessness.
Relationship risk factors: Bullying, loss of relationships, high conflict relationships, social isolation, family or loved one’s history of suicide.
Community risk factors: Suicide in the community, lack of access to healthcare, community violence, historical trauma, stress of acculturation, and discrimination.
Societal risk factors: Access to lethal means, unsafe portrayals of suicide in the media, and stigma associated with seeking help for mental health conditions.
There are also structural conditions that lead to increased risk among minority communities, such as a lack of culturally appropriate care, a lack of representation among healthcare providers, implicit and explicit bias, and structural conditions impacting access and quality of care.
For example, in 2024, Black/African American adults were 36% less likely than U.S. adults overall to have received mental health treatment in the past year (14.7% vs. 22.9%). They were also less likely to receive treatment through prescription medication (8.7% vs. 16.7%)—a gap linked in part to structural barriers like limited access to culturally responsive care and provider bias.
Risk warning signs
Warning signs that a client may be at increased risk may include:
Social isolation
Expressing hopelessness
Increased anxiety
Depression
Talking about being a burden
Sleeping more or less than usual
Mood swings
Looking for access to lethal means
Increased substance use
Anger or rage
Expressing feelings of being trapped or in pain
Talking about wanting to die
Being scared of a person
Cowering
Making plans for suicide
Family history of suicide
How to assess for risk
When a client enters therapy, the therapist will conduct a biopsychosocial assessment that examines the client holistically, including their risk and protective factors. Clinicians may also include structured assessment tools as part of their intake, such as:
Patient Health Questionnaire-9 (PHQ-9): A tool to screen for, evaluate the severity of, and monitor depression.
Columbia Suicide Severity Rating Scale (C-SSRS): The C-SSRS comes in a long and a short version. The detailed screening tool is used in clinical settings, crisis interventions, and research studies. The tool focuses on suicidal ideation, suicide behavior history, intensity of ideation, lethality of attempts, and risk factors. There is a shorter version of C-SSRS, which asks brief questions about suicidal ideation.
Ask Suicide Screening Questions & Brief Suicide Safety Assessment (ASQ BSSA): Developed by the National Institute of Mental Health and designed for patients aged 10 or older, this quick ASQ tool has four screening questions. Depending on the answers, the clinician may proceed with the BSSA, which is a more formal safety assessment tool.
These measures may also be used outside of the intake as part of regular treatment progress monitoring. It’s worth noting that some payers require clinicians to assess and document client risk at each session, which they may do briefly or use one of the above measures.
Each of these measures will provide a score to determine the level of risk, such as passive suicidal ideation, and at that point, the clinician will need to determine the next steps.
Next steps may include:
Further assessment: When assessing risks related to substance use, intimate partner violence, and trauma, there are specialist validated assessment tools, which may require clinical training to administer, including:
American Society of Addiction Medicine (ASAM) assessment: If the therapist is concerned about substance use disorder risk, they may use the American Society of Addiction Medicine free assessment guide, which outlines six dimensions of care with detailed questions and assessment criteria to help clinicians quickly determine the need for emergent referrals and the level of care a client may need.
Historical Clinical Risk Management 20 (HCR-20): A leading risk assessment tool that evaluates the risk of psychological and physical interpersonal violence.
Post Traumatic Stress Disorder Checklist (PCL-5): The PCL-5 is a 20-item self-report measure that monitors symptoms of PTSD. This can be a helpful tool to identify changes in symptom severity and potentially increased risk.
Referral to a specialist, or to a higher level of care, like the crisis teams, the emergency department, an outpatient program, or to a psychiatrist.
Documentation of a safety plan.
Crisis support plan creation.
Ongoing monitoring.
Case management or more frequent sessions.
Medication management.
Risk assessment documentation tips
It is important to make risk assessment documentation notes promptly, which accurately document:
Risk factors.
Suicidal ideation, including intent, plan, motivation, and history. Include Client statements and quotes where appropriate.
Protective factors, including stable housing, employment, responsibilities, coping skills, community support, access to medical care, and social skills.
Clinical observations, including a mental status exam.
Analysis of all of the available information, determination of the client’s perceived risk, and rationale for next steps. Each practice may have its own language for risk level. For example, mild, moderate, or severe risk.
Next steps, such as interventions, referrals, or a safety plan.
Follow-up plan, including the date/time of the client's next follow-up session and any interim check-in points.
Response from client.
Follow-up or consultation with other providers, including a copy of the client's signed release of information.
Reference to supervision or case consultation regarding the client.
How to handle emergencies
It is best practice to provide clients with a list of emergency contacts and crisis contact information during their intake. You can also provide this information on your website, displayed in your office, and in your email signature. This information should address the situations in which clients can contact the clinician and what to do in the event of an emergency.
Each clinician is different, depending on the level of care they provide and the hours they are available. Therapists may advise their clients in a crisis to go to their nearest emergency room or to call their local crisis line.
Some therapists are available to speak with clients for a brief assessment to determine the appropriate next steps, which could include meeting for the next available session, talking with their physician, checking in with a loved one, using their safety plan, or going to the emergency department.
The next step for the therapist is to complete risk assessment documentation in the client record, including relevant information from the encounter (even if they didn’t speak to the client), observations, a determination (if appropriate), and follow-up steps.
When to update the assessment
It is best practice to update the client’s assessment at least every 12 months and their treatment plan every six months or when appropriate. Some payers may also require a note on risk during every client encounter.
Regularly updating risk assessment documentation helps ensure that the client record reflects current risk factors, protective factors, clinical judgment, and interventions.
Sources
American Academy of Pediatrics. (2023). Conducting a brief suicide safety assessment.
Centers for Disease Control and Prevention. (2026). Suicide data and statistics.
Centers for Disease Control and Prevention. (2026). Risk and protective factors for suicide.
Clay, R. (2022). How to assess and intervene with patients at risk of suicide. Monitor on Psychology.
Columbia University Department of Psychiatry. (2021). A simple set of 6 questions to screen for suicide.
Douglas, K. S., Hart, S. D., Webster, C. D., & Belfrage, H. (2013). HCR-20V3: Violence risk assessment scheme. Simon Fraser University.
U.S. Department of Health and Human Services. (2026). Mental health in Black/African Americans.
National Institute of Mental Health. (n.d.). Ask Suicide-Screening Questions (ASQ) toolkit.
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