Curry Health Center
Counseling and Psychological Services
Assessment of: 1) compliance with risk rating form policy for students
with suicidal ideation
ABSTRACT
Therapists are required to submit a risk rating form (RRF) to the Counseling and Psychological
Services Risk Management Committee (CRMC) if a client acknowledges any history of suicidal
behavior. Of the 79 charts examined during this assessment, 13 charts contained reference to
suicidal ideation or behavior but no RRF form was completed. The compliance rate for
individual providers ranged between approximately 65-100%. Beginning fall 2008, additional
improvements will be made to progress note templates and intake chart procedures to help
therapists increase compliance with the requirement. Another follow-up study will be completed
in November 2008 to gauge the effectiveness of these changes.
BACKGROUND
Counseling and Psychological Services (CAPS) conducted this compliance assessment as a
follow-up to a change in charting made as part of a suicidal risk management process
implemented three years ago. Curry Health Center provides affordable, accessible, high quality,
student-centered health services to University of Montana (UM) students to enhance student
learning, promote personal health and development, and teach important life skills. In
accordance with this focus, the mission of CAPS is to support the academic pursuits of UM
students through brief, problem-focused counseling and crisis intervention.
ASSESSMENT PROCEDURE
CAPS inspected current client charts until eight charts for each professional therapist were found
in which the client had acknowledged suicidal ideation on the Personal Information Form which
was completed just before the intake session. Additionally, CAPS selected 3 client charts
containing client references to suicide for each of 5 graduate student therapists. By default, each
chart contained references to suicidal ideation and/or other suicide behavior, and the CRMC
records were subsequently examined to determine whether the therapist had submitted a RRF
form or otherwise notified the CRMC committee of the student’s history of suicidal ideation.
FINDINGS
Of the 79 charts examined there were 13 charts in which there was a reference to suicidal
ideation or behavior but no RRF form was filled out. In all but two of these instances the
suicidal ideation was either in the relatively distant past (e.g., childhood or adolescence) or was
passive and unaccompanied by other major risk factors. There were no charts that indicated that
further therapist action should have been taken for which an RRF was not completed.
Additionally, it was noted that failure to submit an RRF form did not predict failure to document
suicide history in the chart notes. As was predicted and found in the initial study, there was
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variability among therapists with respect to missed documentation of suicidal ideation, with a
range among therapists from zero to three missing RRF forms. The mean for 15 therapists and
student therapists was .86 missing forms, and the compliance rate ranged from approximately
65-100%. As in previous studies, graduate students appeared to be slightly more consistent in
filling out the RRF forms, with only two of 15 charts indicating a missing RRF.
RECOMMENDATIONS
The results strongly suggest the need for improvements in attending to documentation of suicidal
ideation, particularly past and passive instances of ideation. While these are perhaps the students
at the least risk among those CAPS clients who have reported suicidal ideation, the intent of the
RRF procedure and policy is to assess and document 100% of reported ideation or other suicidal
behavior. There is universal agreement among staff that it is sometimes difficult to remember to
fill out the form to rate suicide risk and to detail risk and resilience factors when suicidal ideation
was long in the past, is/was passive, and appears minimally salient given the current reason for
seeking counseling. CAPS began an effort to develop templates for SOAP notes and progress
notes with a forced choice of answering “yes” or ‘no” regarding the presence of any history of
suicidal ideation, and completing a digital RRF form before being able to continue the note.
These efforts were reluctantly abandoned due to the unavailability of such options in the word
processing software used at CAPS. It appears likely that the coming implementation of electronic
health records software will allow such options. In the meantime, therapists clearly need more
effective reminders to complete RRF forms, especially for students for whom perceived risk is
very low.
Beginning fall ’08, SOAP note and progress note templates will be used that include the yellow
highlighted question, “If needed, has an RRF form been completed?” This part of the note will
not be a part of the actual record and the therapist will delete it from the note once s/he has
completed the RRF. Therapists will also receive a blank RRF form in every intake chart so that
they are more readily available for completion when notes are being composed. Unused forms
will eventually be returned to the forms folders behind the reception area.
A follow-up to assess changes in compliance with documentation of all suicidal ideation or
behavior after the above-noted changes have been implemented will be completed in November
2008. The restudy will use the same chart selection process and other methodology that was used
for this study.
Prepared by David Brown PhD., Clinical Psychologist, Curry Health Center
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