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Suicidal Ideation and Self Harm Risk AssessmentAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

373 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Undifferentiated Overdose Opioid Toxicity Opioid Withdrawal Alcohol Intoxication Alcohol Withdrawal Stimulant Toxicity Pediatric Ingestion Carbon Monoxide Exposure Inhalational Or Chemical Exposure Suicidal Ideation And Self Harm Risk Assessment Acute Psychosis And Mania Symptoms Anxiety And Panic Symptoms Capacity Assessment And Safe Disposition Behavioral Escalation And Restraint Considerations

Pediatrics16▾

Environmental and Exposure4▾

01History/hx47

Presenting context

›Context and timeline

›Current thoughts of death

›Suicidal thoughts

›Self harm thoughts

›Self harm behaviors

›Recent escalation in frequency or intensity

›Precipitating stressors

›Interpersonal conflict

›Loss

›Legal or school stress

›Bullying

›Acute intoxication

Intent plan capability access

›Intent plan capability access

›Intent to act

›Specific plan presence

›Capability

›Prior rehearsal behavior

›Access to lethal means in environment

›Means restriction feasibility now

Past suicidal and self harm history

›Prior history

›Prior suicide attempts

›Prior self harm episodes

›Prior psychiatric admissions

›Prior ED visits for crisis

›Prior safety plan effectiveness

02Alarm Features/alarm20

Immediate danger triggers

›Immediate danger

›Current intent with plan and inability to commit to safety in supervised setting

›Severe agitation

›Psychosis with command hallucinations

›Intoxication with impaired judgment

›Recent suicide attempt in last 48 hours

›Medical instability

High risk history triggers

›High risk history

›Prior suicide attempt especially recent

›Repeated self harm with escalating severity

›Recent discharge from psychiatric inpatient unit

›Recent ED visit for suicidal crisis

›Access to lethal means not rapidly restrictable

›Limited supervision at home

Vital sign danger thresholds

›Vital sign danger thresholds

›Hypoxia

›Hypotension

›Tachycardia with suspected toxidrome

›Fever with delirium

›Altered mental status

03Medications/meds15

Current medications with risk relevance

›Medication reconciliation

›Antidepressants

›Antipsychotics

›Mood stabilizers

›Benzodiazepines

›Stimulants

›Opioids

›OTC sleep aids

›Supplements and herbals

High risk medication issues

›High risk medication issues

›Recent start or dose change of psych meds

›Nonadherence

›Drug drug interactions increasing sedation

›Medications with overdose toxicity risk at home

›Access to large quantities of medications

04Diet/diet9

Intake and physiologic vulnerability

›Intake patterns

›Poor oral intake

›Dehydration risk

›Caffeine and energy drinks

›Recent weight loss related to poor intake

›Eating disorder behaviors

Alcohol exposure

›Alcohol exposure

›Recent binge drinking

›Withdrawal risk

05Review of Systems/ros22

Psychiatric symptoms

›Psychiatric ROS

›Depressed mood

›Anhedonia

›Anxiety

›Panic symptoms

›Irritability

›Insomnia

›Hypersomnia

›Manic symptoms

›Psychotic symptoms

›Trauma related symptoms

Neurologic and medical symptoms

›Medical ROS

›Headache

›Syncope

›Seizure

›Chest pain

›Dyspnea

›Abdominal pain

›Nausea

›Vomiting

›Fever

›Ingestion symptoms

06Collateral History and Family History/chafh18

Collateral sources and reliability

›Collateral

›Family or caregiver report

›EMS report

›Police report if applicable

›School report if applicable

›Prior records

›Reliability concerns

Family history

›Family history

›Suicide in first degree relatives

›Mood disorders

›Substance use disorders

›Psychotic disorders

›Firearm access in household

Social supports and supervision

›Supports

›Responsible adult available now

›Ability to provide continuous supervision

›Ability to restrict access to lethal means

›Transportation and follow up reliability

07Risk Factors/rf26

Psychiatric and psychosocial risk

›Psychiatric risk factors

›Major depressive disorder (F32.9)

›Bipolar disorder (F31.9)

›Substance use disorder (F19.90)

›Psychotic disorder (F29)

›PTSD (F43.10)

›Borderline personality disorder traits (F60.3)

›Recent interpersonal violence exposure

›Recent homelessness or housing insecurity

Medical and neurocognitive risk

›Medical risk factors

›Chronic pain

›Traumatic brain injury history

›Neurodevelopmental disorders

›Cognitive impairment

Situational and access risks

›Situational and access risks

›Recent loss

›Legal stress

›Easy access to lethal means at home

›Social isolation

›Recent intoxication pattern

Pediatric and adolescent specific risks

›Pediatric and adolescent risks

›Bullying

›School stress

›Family conflict

08Differential Diagnosis/ddx39

Life threatening

›Life threatening

›Suicide attempt with occult medical injury

›Toxidrome

›Hypoxia

›Acute intoxication or withdrawal

›Alcohol withdrawal

›Sedative hypnotic withdrawal

›Acute psychosis

›Primary psychotic disorder

›Substance induced psychosis

›Delirium

›Infection

›Metabolic derangement

Common

›Common

›Major depressive disorder (F32.9)

›Persistent low mood

›Anhedonia

›Anxiety disorders (F41.9)

›Panic symptoms

›Rumination

›Adjustment disorder (F43.20)

›Clear precipitant

›Time limited course

›Substance use disorder (F19.90)

›Intoxication linked crisis

›Withdrawal linked dysphoria

09Past Medical History/pmh19

Psychiatric and behavioral history

›Psychiatric PMH

›Diagnosed psychiatric conditions

›Prior hospitalizations

›Prior suicide attempts

›Prior self harm history

›Prior violence history

›Prior trauma history

Medical history relevant to tox or delirium

›Medical PMH

›Seizure disorder

›Diabetes mellitus (E11.9)

›Renal disease (N18.9)

›Liver disease (K76.9)

›Pregnancy

Social history

›Social history

›Housing stability

›Access to care

›Supports

›School or work functioning

›Legal involvement

10Physical Exam/exam23

General and safety

›General exam

›Level of consciousness

›Distress level

›Psychomotor agitation

›Psychomotor retardation

›Evidence of intoxication

›Evidence of recent injury

Mental status exam

›Mental status

›Appearance and behavior

›Speech

›Mood and affect

›Thought process

›Thought content

›Perception abnormalities

›Insight

›Judgment

Neurologic and cardiopulmonary

›Focused medical exam

›Pupils and nystagmus for toxidrome

›Respiratory pattern

›Skin findings of toxidrome

›Tremor

›Hyperreflexia

›Rigidity

11Lab Studies/labs15

Core labs when medically indicated

›Core labs

›Glucose point of care

›Electrolytes

›Renal function

›Liver enzymes

›CBC

›Pregnancy test when applicable

Toxicology and ingestion evaluation

›Toxicology

›Blood alcohol level when clinically indicated

›Urine drug screen with limitation awareness

›Acetaminophen level when ingestion possible

›Salicylate level when ingestion possible

Limitations and pitfalls

›Limitations

›Urine drug screen does not rule out intoxication

›Normal labs do not exclude imminent suicide risk

12Imaging/img20

Scoring Systems

›Structured risk frameworks

›SAFE T framework

›Risk factors

›Protective factors

›Suicidal inquiry

›Risk level formulation

›Intervention planning

›Columbia Suicide Severity Rating Scale

›Severity of ideation

›Intensity of ideation

›Suicidal behavior history

MRI

›MRI

›Neuroimaging only if focal neurologic findings

›Neuroimaging only if delirium without clear cause

›CT

›CT head if head trauma suspected

›CT as local protocol dependent for unexplained altered mental status

Ultrasound

›Ultrasound

›POCUS for trauma evaluation if injury suspected

›POCUS guidance for IV access if difficult access

13Special Tests/spec7

Bedside screening and assessment tools

›Screening tools

›ASQ screen for youth where used

›Brief Suicide Safety Assessment after positive screen

›C SSRS structured questions

Toxicology focused bedside tests

›Bedside tox tests

›Capnography if sedative exposure suspected

›Serial vital sign reassessment for toxidrome evolution

14ECG/ecg5

ECG indications and high risk findings

›ECG

›ECG if ingestion possible

›QT prolongation risk assessment

›QRS widening risk assessment

›Arrhythmia monitoring if toxidrome suspected

15Assessment/ax18

Risk formulation

›Risk formulation

›Imminent risk

›Current intent with plan

›Inability to ensure safety in supervised setting

›High risk

›Recent attempt

›Severe symptoms

›Moderate risk

›Suicidal ideation without current intent

›Protective factors present but limited

›Lower risk

›Passive thoughts only

›Strong protective factors

Medical clearance and comorbidity assessment

›Medical assessment

›Intoxication contribution

›Withdrawal contribution

›Delirium contribution

›Coexisting medical instability

16Plan/plan36

Differential Management

›!Suicidal ideation and attempt→›!Major depressive episode→›Acute psychosis→

First 5 minutes

›First 5 minutes

›Immediate safety observation level per local protocol dependent

›Remove access to potential hazards in care area per local protocol dependent

›Continuous monitoring if intoxication suspected

›Rapid vitals reassessment schedule

›Point of care glucose if altered mental status

Diagnostic plan and sequencing

›Diagnostic plan

›Structured suicide risk assessment

›Collateral collection early

›Review prior records for recent attempts and admissions

›Tox and medical workup only if indicated by history exam vitals

Therapeutic plan

›Therapeutic plan

›Treat medical instability first

›Treat agitation with least sedating option appropriate to cause local protocol dependent

›Manage withdrawal if present local protocol dependent

›Address pain nausea or other drivers

Safety planning and means safety

›Safety planning

›Collaborative safety plan

›Warning signs and coping strategies

›Support contacts

17Disposition/dispo20

ICU and monitored care

›ICU and monitored care

›Medical instability

›Severe intoxication requiring airway support

›Significant arrhythmia or ECG toxicity

Inpatient psychiatric admission

›Inpatient psych

›Imminent risk

›High risk with poor supports

›Psychosis with safety concerns

›Inability to engage in safety plan

Observation pathway

›Observation

›Intoxication requiring time for reliable assessment

›Moderate risk with uncertain collateral

›Need for brief crisis stabilization

Discharge criteria

›Discharge criteria

›No current intent

›No acute psychosis or delirium

›Supportive responsible adult available

›Feasible means restriction

›Safety plan completed

›Rapid follow up arranged within 24 to 72 hours local protocol dependent

18Discharge Instructions/di8

Copy discharge instructions

›Copy discharge instructions

›You were seen today for suicidal thoughts or self harm concerns

›If you feel you might act on these thoughts call emergency services or go to the nearest emergency department now

›Do not stay alone until you are feeling safe

›Remove or secure anything at home that could be used to seriously hurt yourself with help from an adult you trust

›Follow up with your mental health provider within 24 to 72 hours

›If you do not have a provider follow up with your primary care clinician or local crisis service within 24 to 72 hours

›Return now for worsening thoughts of self harm new plan increasing intent severe anxiety agitation hallucinations or intoxication

19References/r6

Guidelines and key sources

›References

›NICE guideline NG225 Self harm assessment management and preventing recurrence 2022

›VA DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide 2024 Version 3.0

›Joint Commission National Patient Safety Goal NPSG 15.01.01 Reduce the Risk for Suicide

›BMJ Practice Pointer assessment and management of self harm and suicide risk in young people 2024

›StatPearls Suicide Assessment and Management 2025

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Suicidal Ideation and Self Harm Risk AssessmentAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

373 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx47

Presenting context

›Context and timeline

›Current thoughts of death

›Suicidal thoughts

›Self harm thoughts

›Self harm behaviors

›Recent escalation in frequency or intensity

›Precipitating stressors

›Interpersonal conflict

›Loss

›Legal or school stress

›Bullying

›Acute intoxication

Intent plan capability access

›Intent plan capability access

›Intent to act

›Specific plan presence

›Capability

›Prior rehearsal behavior

›Access to lethal means in environment

›Means restriction feasibility now

Past suicidal and self harm history

›Prior history

›Prior suicide attempts

›Prior self harm episodes

›Prior psychiatric admissions

›Prior ED visits for crisis

›Prior safety plan effectiveness

02Alarm Features/alarm20

Immediate danger triggers

›Immediate danger

›Current intent with plan and inability to commit to safety in supervised setting

›Severe agitation

›Psychosis with command hallucinations

›Intoxication with impaired judgment

›Recent suicide attempt in last 48 hours

›Medical instability

High risk history triggers

›High risk history

›Prior suicide attempt especially recent

›Repeated self harm with escalating severity

›Recent discharge from psychiatric inpatient unit

›Recent ED visit for suicidal crisis

›Access to lethal means not rapidly restrictable

›Limited supervision at home

Vital sign danger thresholds

›Vital sign danger thresholds

›Hypoxia

›Hypotension

›Tachycardia with suspected toxidrome

›Fever with delirium

›Altered mental status

03Medications/meds15

Current medications with risk relevance

›Medication reconciliation

›Antidepressants

›Antipsychotics

›Mood stabilizers

›Benzodiazepines

›Stimulants

›Opioids

›OTC sleep aids

›Supplements and herbals

High risk medication issues

›High risk medication issues

›Recent start or dose change of psych meds

›Nonadherence

›Drug drug interactions increasing sedation

›Medications with overdose toxicity risk at home

›Access to large quantities of medications

04Diet/diet9

Intake and physiologic vulnerability

›Intake patterns

›Poor oral intake

›Dehydration risk

›Caffeine and energy drinks

›Recent weight loss related to poor intake

›Eating disorder behaviors

Alcohol exposure

›Alcohol exposure

›Recent binge drinking

›Withdrawal risk

05Review of Systems/ros22

Psychiatric symptoms

›Psychiatric ROS

›Depressed mood

›Anhedonia

›Anxiety

›Panic symptoms

›Irritability

›Insomnia

›Hypersomnia

›Manic symptoms

›Psychotic symptoms

›Trauma related symptoms

Neurologic and medical symptoms

›Medical ROS

›Headache

›Syncope

›Seizure

›Chest pain

›Dyspnea

›Abdominal pain

›Nausea

›Vomiting

›Fever

›Ingestion symptoms

06Collateral History and Family History/chafh18

Collateral sources and reliability

›Collateral

›Family or caregiver report

›EMS report

›Police report if applicable

›School report if applicable

›Prior records

›Reliability concerns

Family history

›Family history

›Suicide in first degree relatives

›Mood disorders

›Substance use disorders

›Psychotic disorders

›Firearm access in household

Social supports and supervision

›Supports

›Responsible adult available now

›Ability to provide continuous supervision

›Ability to restrict access to lethal means

›Transportation and follow up reliability

07Risk Factors/rf26

Psychiatric and psychosocial risk

›Psychiatric risk factors

›Major depressive disorder (F32.9)

›Bipolar disorder (F31.9)

›Substance use disorder (F19.90)

›Psychotic disorder (F29)

›PTSD (F43.10)

›Borderline personality disorder traits (F60.3)

›Recent interpersonal violence exposure

›Recent homelessness or housing insecurity

Medical and neurocognitive risk

›Medical risk factors

›Chronic pain

›Traumatic brain injury history

›Neurodevelopmental disorders

›Cognitive impairment

Situational and access risks

›Situational and access risks

›Recent loss

›Legal stress

›Easy access to lethal means at home

›Social isolation

›Recent intoxication pattern

Pediatric and adolescent specific risks

›Pediatric and adolescent risks

›Bullying

›School stress

›Family conflict

08Differential Diagnosis/ddx39

Life threatening

›Life threatening

›Suicide attempt with occult medical injury

›Toxidrome

›Hypoxia

›Acute intoxication or withdrawal

›Alcohol withdrawal

›Sedative hypnotic withdrawal

›Acute psychosis

›Primary psychotic disorder

›Substance induced psychosis

›Delirium

›Infection

›Metabolic derangement

Common

›Common

›Major depressive disorder (F32.9)

›Persistent low mood

›Anhedonia

›Anxiety disorders (F41.9)

›Panic symptoms

›Rumination

›Adjustment disorder (F43.20)

›Clear precipitant

›Time limited course

›Substance use disorder (F19.90)

›Intoxication linked crisis

›Withdrawal linked dysphoria

09Past Medical History/pmh19

Psychiatric and behavioral history

›Psychiatric PMH

›Diagnosed psychiatric conditions

›Prior hospitalizations

›Prior suicide attempts

›Prior self harm history

›Prior violence history

›Prior trauma history

Medical history relevant to tox or delirium

›Medical PMH

›Seizure disorder

›Diabetes mellitus (E11.9)

›Renal disease (N18.9)

›Liver disease (K76.9)

›Pregnancy

Social history

›Social history

›Housing stability

›Access to care

›Supports

›School or work functioning

›Legal involvement

10Physical Exam/exam23

General and safety

›General exam

›Level of consciousness

›Distress level

›Psychomotor agitation

›Psychomotor retardation

›Evidence of intoxication

›Evidence of recent injury

Mental status exam

›Mental status

›Appearance and behavior

›Speech

›Mood and affect

›Thought process

›Thought content

›Perception abnormalities

›Insight

›Judgment

Neurologic and cardiopulmonary

›Focused medical exam

›Pupils and nystagmus for toxidrome

›Respiratory pattern

›Skin findings of toxidrome

›Tremor

›Hyperreflexia

›Rigidity

11Lab Studies/labs15

Core labs when medically indicated

›Core labs

›Glucose point of care

›Electrolytes

›Renal function

›Liver enzymes

›CBC

›Pregnancy test when applicable

Toxicology and ingestion evaluation

›Toxicology

›Blood alcohol level when clinically indicated

›Urine drug screen with limitation awareness

›Acetaminophen level when ingestion possible

›Salicylate level when ingestion possible

Limitations and pitfalls

›Limitations

›Urine drug screen does not rule out intoxication

›Normal labs do not exclude imminent suicide risk

12Imaging/img20

Scoring Systems

›Structured risk frameworks

›SAFE T framework

›Risk factors

›Protective factors

›Suicidal inquiry

›Risk level formulation

›Intervention planning

›Columbia Suicide Severity Rating Scale

›Severity of ideation

›Intensity of ideation

›Suicidal behavior history

MRI

›MRI

›Neuroimaging only if focal neurologic findings

›Neuroimaging only if delirium without clear cause

›CT

›CT head if head trauma suspected

›CT as local protocol dependent for unexplained altered mental status

Ultrasound

›Ultrasound

›POCUS for trauma evaluation if injury suspected

›POCUS guidance for IV access if difficult access

13Special Tests/spec7

Bedside screening and assessment tools

›Screening tools

›ASQ screen for youth where used

›Brief Suicide Safety Assessment after positive screen

›C SSRS structured questions

Toxicology focused bedside tests

›Bedside tox tests

›Capnography if sedative exposure suspected

›Serial vital sign reassessment for toxidrome evolution

14ECG/ecg5

ECG indications and high risk findings

›ECG

›ECG if ingestion possible

›QT prolongation risk assessment

›QRS widening risk assessment

›Arrhythmia monitoring if toxidrome suspected

15Assessment/ax18

Risk formulation

›Risk formulation

›Imminent risk

›Current intent with plan

›Inability to ensure safety in supervised setting

›High risk

›Recent attempt

›Severe symptoms

›Moderate risk

›Suicidal ideation without current intent

›Protective factors present but limited

›Lower risk

›Passive thoughts only

›Strong protective factors

Medical clearance and comorbidity assessment

›Medical assessment

›Intoxication contribution

›Withdrawal contribution

›Delirium contribution

›Coexisting medical instability

16Plan/plan36

Differential Management

›!Suicidal ideation and attempt→›!Major depressive episode→›Acute psychosis→

First 5 minutes

›First 5 minutes

›Immediate safety observation level per local protocol dependent

›Remove access to potential hazards in care area per local protocol dependent

›Continuous monitoring if intoxication suspected

›Rapid vitals reassessment schedule

›Point of care glucose if altered mental status

Diagnostic plan and sequencing

›Diagnostic plan

›Structured suicide risk assessment

›Collateral collection early

›Review prior records for recent attempts and admissions

›Tox and medical workup only if indicated by history exam vitals

Therapeutic plan

›Therapeutic plan

›Treat medical instability first

›Treat agitation with least sedating option appropriate to cause local protocol dependent

›Manage withdrawal if present local protocol dependent

›Address pain nausea or other drivers

Safety planning and means safety

›Safety planning

›Collaborative safety plan

›Warning signs and coping strategies

›Support contacts

17Disposition/dispo20

ICU and monitored care

›ICU and monitored care

›Medical instability

›Severe intoxication requiring airway support

›Significant arrhythmia or ECG toxicity

Inpatient psychiatric admission

›Inpatient psych

›Imminent risk

›High risk with poor supports

›Psychosis with safety concerns

›Inability to engage in safety plan

Observation pathway

›Observation

›Intoxication requiring time for reliable assessment

›Moderate risk with uncertain collateral

›Need for brief crisis stabilization

Discharge criteria

›Discharge criteria

›No current intent

›No acute psychosis or delirium

›Supportive responsible adult available

›Feasible means restriction

›Safety plan completed

›Rapid follow up arranged within 24 to 72 hours local protocol dependent

18Discharge Instructions/di8

Copy discharge instructions

›Copy discharge instructions

›You were seen today for suicidal thoughts or self harm concerns

›If you feel you might act on these thoughts call emergency services or go to the nearest emergency department now

›Do not stay alone until you are feeling safe

›Remove or secure anything at home that could be used to seriously hurt yourself with help from an adult you trust

›Follow up with your mental health provider within 24 to 72 hours

›If you do not have a provider follow up with your primary care clinician or local crisis service within 24 to 72 hours

›Return now for worsening thoughts of self harm new plan increasing intent severe anxiety agitation hallucinations or intoxication

19References/r6

Guidelines and key sources

›References

›NICE guideline NG225 Self harm assessment management and preventing recurrence 2022

›VA DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide 2024 Version 3.0

›Joint Commission National Patient Safety Goal NPSG 15.01.01 Reduce the Risk for Suicide

›BMJ Practice Pointer assessment and management of self harm and suicide risk in young people 2024

›StatPearls Suicide Assessment and Management 2025

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.