A suicide risk assessment note should record what you asked, what the person said, how you understood their risk (the formulation), what you and the person agreed to do, and when you will review it. Current Australian guidance moves away from rating risk as low, medium or high, because those categories do not predict who will die by suicide.

If you or someone you are supporting needs help now, Lifeline is available 24 hours a day on 13 11 14, the Suicide Call Back Service on 1300 659 467, and 13YARN on 13 92 76 for Aboriginal and Torres Strait Islander callers.

What does a suicide risk assessment note need to show?

A risk note is not a form you tick. It is the record of a clinical decision, and the only durable evidence of it if the person deteriorates, a family asks questions, or a coroner or regulator reads the file years later. A defensible note shows six things:

What you asked, including direct questions about intent, plan, previous attempts and access to means, recorded as asked and answered rather than summarised as "risk assessed".
What the person said, in their own words where the words matter.
What you observed, including the relevant parts of the mental state examination.
Your formulation, meaning how you understand this person's risk now and what is driving it.
What was agreed, including the safety plan, involvement of family or carers, and referrals made.
The review point, meaning when this will be revisited and by whom.

NSW Health's policy directive Clinical care of people who may be suicidal (PD2022_043) tells clinicians to "ensure clinical records document ongoing mental health state, assessment and risk formulation, safety planning, treatment, suicide care planning, review, transition and follow-up". It binds NSW public services rather than private practices, but it is the clearest published statement of what Australian services now expect.

Why does "low, medium or high risk" no longer belong in the note?

Because it does not work, and Australian policy now says so. PD2022_043 defines risk stratification as "a systematic process to classify patients who are at risk of suicide, and inform interventions offered", then adds: "This is not the current best practice approach; mental health services and clinicians are to offer treatment for the individual based on comprehensive individual assessment."

The evidence is a 2016 meta-analysis of longitudinal cohort studies published in PLOS ONE by Large and colleagues. High-risk categorisation had a pooled sensitivity of 56% and specificity of 79%, and "just over half of all suicides occurred in the lower-risk groups". The authors concluded that "a statistically strong and reliable method to usefully distinguish patients with a high-risk of suicide remains elusive".

The documentation consequence is practical. A note that says "low risk" carries almost no information, cannot be defended later, and can read as the reason care was not offered.

What is a suicide prevention formulation, and how do you write one?

Formulation is the part most notes are missing. PD2022_043 describes it as synthesising the assessment into an understanding of the person, aiming "to capture how a person's history and context interact to produce and mitigate suicide risk", and includes:

the risk factors the person presents, and which of them are modifiable
the person's internal coping resources and how they can be strengthened
external resources such as family, social network, professional supports or wider community
the changeability of the current situation, including relationships and external factors

Written down, that is three or four sentences, not a page. The test is whether a colleague reading it at 9pm would understand why you decided what you decided. A formulation that could apply to any client is not a formulation.

How should a safety plan be documented?

Safety planning is collaborative, and PD2022_043 sets out what it covers: warning signs, internal coping strategies, social contacts that may distract from suicidal thoughts, social supports who can help resolve the crisis, professional supports, and counselling on access to lethal means. It also states that "in addition to the person having a copy of the safety plan, a copy must be documented in the electronic medical record (eMR) system". Two copies matters: a plan the person cannot reach during a crisis is not an intervention, and a plan that exists only on their phone leaves your record unable to show what was agreed.

The evidence supports the effort. A 2018 JAMA Psychiatry cohort comparison by Stanley and colleagues found that safety planning with structured follow-up "was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03)". The model is the Stanley-Brown Safety Planning Intervention; in Australia the free Beyond Now app, built by Beyond Blue and Monash University and transferred to Lifeline in March 2024, gives clients a version they carry with them.

Record that the plan was made collaboratively, that the person has a copy, where your copy lives, and that access to means was discussed and with whom.

What does a documented risk assessment look like?

The example below is fictional. Note what it does: it quotes, it separates asked-and-denied from not-asked, it formulates, and it names a review point.

Suicidal ideation. Reports worsening sleep and "no point being here" thoughts most days since separation confirmed on 3 August. Passive ideation daily, minutes to an hour, described as "wishing I didn't wake up". Denies current intent. Denies plan when asked directly. Access to means: no firearms; medications held at home in usual quantities, agreed tonight to store them with his sister. One previous attempt in 2019 during heavy alcohol use, no admission; no self-harm in the past 12 months.

Protective factors and mental state. Care of 8 year old son described as "the reason I get up". Sister in regular contact and aware of current distress. Alert, tearful twice, speech slowed, mood quoted as "flat and wrung out", affect congruent and reactive in parts, insight intact.

Formulation. Passive ideation appears driven by acute relationship loss and sleep disruption in a man with a prior attempt during heavy alcohol use, offset by strong attachment to his son, an available and informed sister, and willingness to engage. Modifiable this fortnight: sleep, alcohol use, weekend isolation and medication access. Risk is expected to fluctuate with contact arrangements for his son, and the next Family Court date is a foreseeable pressure point.

Safety plan. Completed collaboratively using Beyond Now: warning signs, two internal coping strategies, sister and one friend as contacts, GP and this service as professional supports, Lifeline 13 11 14 listed. Copy on client's phone, copy filed to record. Medication storage with sister agreed.

Plan and review. Consent obtained to send a summary to his GP; client declined further family involvement. Weekly sessions for four weeks, next appointment 25 August. Client agreed to contact this service or Lifeline if intent emerges. Reassess ideation, sleep and alcohol each session, and around the court date.

That note takes minutes to write and shows an assessment, a formulation, an intervention and a review, without a single risk rating.

What must you record when you disclose without consent?

Two different rules apply, and they are routinely confused.

The Psychology Board of Australia's Code of conduct, effective 1 December 2025, says clients have a right to expect information is held in confidence "unless the release of information is required or authorised by law or is required to facilitate emergency service provision".

Under the Australian Privacy Principles, APP 6.2 permits disclosure for a secondary purpose where "a permitted general situation exists" (which covers lessening or preventing a serious threat to life, health or safety when consent is unreasonable or impracticable to obtain), and separately where disclosure is "reasonably necessary for one or more enforcement related activities conducted by, or on behalf of, an enforcement body". Only the second carries a statutory paperwork obligation: APP 6.5 states that if you disclose "in accordance with paragraph 6.2(e), the entity must make a written note of the use or disclosure". In plain terms, a disclosure to police is the one that legally requires a written note.

Calling an ambulance or a next of kin under the serious-threat pathway does not trigger APP 6.5, but leaving it undocumented is indefensible anyway. Record who you told, what you told them, when, what you believed at the time that justified it, and whether the client was informed.

Which record-keeping standards apply to a risk note?

The same standards as every clinical record, with sharper edges. Section 8.5 of the Board's Code asks psychologists to keep records that are "accurate, up to date, factual, objective, legible and accessible", to "make records at the time of events or as soon as possible afterwards", and to ensure records "do not include demeaning or derogatory remarks". Writing contemporaneously matters more here than anywhere: a risk note written three days later, after an incident, invites the question of whether it records what you knew then or what you wished you had known. On retention, the Code sets a floor of seven years from the last entry for adults and until the 25th birthday for clients who were under 18 at the last entry, and our guide to how long to keep clinical records in Australia covers the state variations.

Two habits help. Record the limits of confidentiality at intake rather than at the crisis, since the Code expects clients to be "adequately informed about the limits of confidentiality" at the beginning of a service. And carry risk forward into the treatment plan instead of leaving it stranded in one session note.

What are the most common documentation mistakes?

Rating instead of reasoning. "Low risk, no plan" tells a reader nothing about what you asked or why you were reassured.
Silence where a question was asked. If you asked about intent and the person denied it, write that. An empty field reads later as a question never asked.
Copying forward last week's risk paragraph. Duplicated text across sessions undermines the credibility of the whole record.
Loaded language. "Manipulative" and "attention seeking" are opinions that fail the factual and respectful tests in section 8.5, and they follow a person through their file.
No review point. A risk note with no next step reads as an assessment that ended with the session.

Can an AI scribe write a risk assessment note?

It can draft the descriptive parts, which helps when the alternative is writing up a distressing session at 8pm from memory. What it cannot do is form the clinical judgement. The formulation, the disclosure decision, the review interval and the sign-off are yours, and Ahpra expects content generated with AI assistance to be reviewed and approved by the practitioner, as our summary of Ahpra's AI guidance sets out.

PractaLuma is AI-native practice management software for Australian mental-health practices. Its clinical notes and AI scribe features let a practice build risk-specific templates with formulation and safety plan sections built in, so the structure prompts the clinician rather than the clinician remembering it under pressure. Plans are listed in the pricing section.

Frequently asked questions

Should I ever write "low risk" in a note? Avoid it as a conclusion. If a service form requires a category, record it alongside the formulation rather than instead of it, so the record still carries the reasoning a category cannot.

Do I need a separate risk form, or can it live in the progress note? Either works if the content is findable. Many practices use a dedicated section in the progress note, with the safety plan attached as its own document.

What do I write when a client refuses a safety plan? Record the offer, the refusal, the reasons given, what you did instead, what supports were still put in place, and when you will revisit it. A documented refusal is a clinical fact, not a gap.

Does the note need to name the crisis services I gave? Yes. "Crisis numbers provided" cannot be verified later; "Lifeline 13 11 14 and the local mental health line recorded in the safety plan" can.

This article is general information for clinicians about documentation practice. It is not clinical, legal or regulatory advice, and it does not replace your professional obligations, your service's policies, or supervision. Requirements differ between states, territories and professions. If you or someone you know needs support, contact Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467, or 13YARN on 13 92 76. In an emergency, call 000.

How to Document a Suicide Risk Assessment (Australia)