Ask directly
Use clear, calm language about suicide, self-harm, violence, abuse, access to means, and ability to stay safe.
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Metropolitan General Health System
PMHNP Clinical Learning Environment
Assessment Resource
Safety & Risk Assessment
Safety assessment is a direct, collaborative evaluation of possible harm, vulnerability, acute impairment, protective factors, and the patient's ability to remain safe in the current setting. The goal is not to predict the future with certainty—it is to identify actionable risk and choose the safest clinically appropriate response.
Assess beyond words
Integrate behavior, affect, reliability, collateral, records, recent events, substances, medical status, and the environment.
Separate acute from chronic
Long-standing vulnerability and near-term escalation both matter, but they answer different clinical questions.
Act on the formulation
Documentation is incomplete until the findings are connected to interventions, level of care, and follow-up.
Core safety domains
Assess the whole safety picture
Depth varies by presentation and setting. A positive response, concerning behavior, unreliable history, or meaningful clinical change should prompt focused follow-up rather than a rapid yes-or-no conclusion.
01
Suicide & self-harm
Assess: Current and recent thoughts, wish to die, intent, plan, preparation, access to means, rehearsal, interrupted or aborted attempts, prior attempts, nonsuicidal self-injury, and reasons for living.
Clinical focus: Ask directly and separately about passive death wishes, suicidal thoughts, suicidal behavior, and self-injury; they are related but not interchangeable.
02
Harm toward others
Assess: Thoughts, threats, intent, targets, plans, access to weapons or other means, past violence, escalating conflict, command hallucinations, persecutory beliefs, impulse control, and substance involvement.
Clinical focus: Explore specificity, imminence, capacity, access, history, and identifiable potential victims rather than documenting only “denies HI.”
03
Vulnerability & self-neglect
Assess: Ability to obtain food, shelter, medication, and medical care; exploitation, abuse, trafficking, falls, wandering, unsafe relationships, cognitive impairment, and caregiving concerns.
Clinical focus: Consider developmental stage, disability, pregnancy, older age, dependence on others, and whether the patient can recognize or respond to danger.
04
Acute impairment
Assess: Intoxication or withdrawal, delirium, mania, psychosis, severe depression, agitation, catatonia, sleep deprivation, medication toxicity, and rapidly changing medical or neurologic status.
Clinical focus: Determine whether the person can participate reliably, use judgment, control behavior, and follow a safety plan in the current state.
05
Environmental risk
Assess: Access to firearms, medications, toxic substances, ligatures, vehicles, heights, or other lethal means; living situation; supervision; recent losses; legal or financial crises; and exposure to violence.
Clinical focus: Ask about actual access and storage—not merely ownership—and involve supports when appropriate, lawful, and clinically necessary.
06
Protective factors & supports
Assess: Connectedness, dependents, values, spirituality, future goals, treatment engagement, coping skills, problem-solving ability, stable housing, supportive relationships, and willingness to accept help.
Clinical focus: Protective factors matter, but they do not cancel acute intent, preparation, impaired control, or access to highly lethal means.
When a concern is identified
Move from acknowledgment to specificity
Follow the patient's words with respectful questions about frequency, duration, intensity, controllability, triggers, deterrents, planning, preparation, access, behavior, and what stopped the person from acting. Establish what is happening now, not only what happened at the worst point.
Evidence-based suicide care
Know the role of the “Big Three”
These frameworks work together, but they are not interchangeable. The C-SSRS supports structured identification, SAFE-T guides formulation and triage, and the Stanley-Brown intervention turns the response into a collaborative safety plan. None replaces a comprehensive clinical assessment, setting-specific policy, or clinical judgment.
01
SAFE-T
Formulation & triage
Suicide Assessment Five-Step Evaluation and Triage
Identify modifiable and nonmodifiable risk factors, identify protective factors, conduct a suicide inquiry, determine the risk level and intervention, and document the assessment and plan. Use it to integrate chronic vulnerability with acute change—not to reduce the patient to a score.
02
C-SSRS
Structured screening
Columbia-Suicide Severity Rating Scale
Use plain-language questions to identify and characterize suicidal ideation and behavior, including severity, intensity, recency, and actual, interrupted, aborted, or preparatory behavior. A positive screen requires clinical follow-up; the tool does not determine disposition by itself.
03
Stanley-Brown SPI
Collaborative intervention
Safety Planning Intervention
Build a brief, personalized, stepwise plan the patient can use during a suicidal crisis. Warning signs, coping strategies, social and professional supports, and a safer environment are developed collaboratively and rehearsed for real-world use.
Clinical formulation
Translate findings into a defensible response
What is happening now?
Identify current thoughts, behaviors, intent, means, symptoms, stressors, and the patient’s ability to maintain safety.
What has changed?
Compare the present state with baseline and identify escalation, loss of supports, new access, recent discharge, or other acute shifts.
What increases vulnerability?
Integrate prior behavior, psychiatric and medical conditions, trauma, substance use, impulsivity, chronic pain, and social context.
What reduces risk?
Identify specific supports, internal coping strategies, treatment engagement, reasons for living, and environmental protections.
What must happen next?
Match the response, setting, monitoring, consultation, and follow-up intensity to the full clinical picture.
Means restriction / lethal means safety
Create time and distance from a lethal method
Means restriction is an active, patient-centered suicide-prevention intervention. It reduces immediate access to a potentially lethal method during a period of elevated risk. Discuss it even when a patient has not disclosed a specific plan, and tailor the approach to the person, household, method, culture, and clinical setting.
Ask specifically
Assess access—not only ownership—to firearms, medications, toxic substances, sharp objects, ligatures, heights, vehicles, or any method the patient has considered.
Make the plan concrete
Identify what will be removed, secured, transferred, limited, or supervised; by whom; for how long; and how the change will be verified.
Prioritize the most lethal and available means
Address the patient’s stated method first while also considering other readily accessible methods. Do not assume that absence of a disclosed plan eliminates the need for means safety.
Collaborate without judgment
Use calm, practical language and explain that the goal is to create time and distance during periods of acute risk—not to punish, shame, or debate lawful ownership.
Reassess feasibility
Confirm that the patient and involved supports can carry out the plan. If access cannot be reduced adequately, reconsider supervision, setting, and level of care.
Document the intervention
Record the means discussed, current access and storage, agreed changes, participating supports, unresolved barriers, and how the plan affected disposition.
Escalation
Recognize when the current setting is insufficient
Current intent or preparation, inability to maintain safety, access to lethal means with escalating risk, severe intoxication or withdrawal, delirium, uncontrolled agitation, command hallucinations with impaired control, targeted violence risk, or rapidly changing medical or psychiatric status may require immediate containment, medical evaluation, emergency consultation, or transfer to a higher level of care.
- Do not leave a person with imminent safety concerns alone.
- Use the emergency procedures and supervisory chain for the setting.
- Address urgent medical contributors and intoxication or withdrawal.
- Obtain collateral and involve supports when clinically and legally appropriate.
- Document the evidence, consultation, actions, and disposition clearly.
Collaborative intervention
Safety planning is more than a contact list
When outpatient management is clinically appropriate, develop a brief, personalized, usable plan with the patient. Rehearse how it will be used, identify barriers, share it as appropriate, and arrange timely follow-up and reassessment.
- Personal warning signs that a crisis may be developing
- Internal coping strategies the person can use independently
- People and places that provide distraction or connection
- Trusted people who can help during a crisis
- Clinicians, crisis services, and emergency options
- Concrete steps to reduce access to lethal means
Denies SI/HI. Low risk. Contracts for safety. Follow up as scheduled.
Reports intermittent passive wishes not to wake up during the past week but denies current suicidal intent, plan, preparation, or prior attempts. Identifies worsening insomnia and recent relationship loss as acute stressors. No firearm access reported; medications are currently stored in an unlocked shared cabinet. Remains future oriented toward completing the semester, names two available supports, and engages in collaborative safety planning. Plan addresses medication access, warning signs, support contacts, urgent-care options, follow-up interval, and circumstances requiring immediate reassessment.
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Context and equity
Ask what safety means in this patient's life
Language, culture, disability, neurodivergence, stigma, prior coercive care, immigration concerns, family roles, community violence, housing, transportation, cost, and access to treatment can shape both disclosure and the feasibility of a plan. Use qualified interpreters when needed and avoid treating reluctance, mistrust, or culturally shaped communication as proof of risk or safety.