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Mental Health Risk Assessment Documentation Audit

Audit the quality and safety of mental health risk assessment documentation.

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Overview

This project measures the quality, completeness and safety of mental health risk assessment documentation across inpatient, liaison, crisis and community mental health settings. It reflects national guidance that risk assessment is a structured clinical process producing a formulation, a safety plan and clear review arrangements — not a score used to predict risk or determine access to care.

Specialties, services & categories

Clinical specialties:Mental Health / PsychiatryLiaison PsychiatryAcute Medicine
Healthcare services:Clinical GovernanceNursing & AHPs
Categories:Patient SafetyGovernance

Who should use it

  • Psychiatry trainees, SAS doctors and consultants
  • Mental health nurses and AHPs
  • Liaison psychiatry and crisis teams
  • Mental health governance and audit leads

Objectives

  • Measure completion and timeliness of mental health risk assessment documentation
  • Assess whether suicide, self-harm, risk to others, self-neglect and safeguarding are documented
  • Assess whether a narrative risk formulation and safety plan are recorded, not a score alone
  • Identify documentation gaps by location, team and assessment setting
  • Generate governance-ready and ARCP-ready evidence

Data collected

  • Anonymous case identifier
  • Inclusion / eligibility decision
  • Assessment setting and location recorded in project setup
  • Ten documentation and safety criteria (met / not met / not applicable)
  • Free-text comments and any project custom fields

Outputs generated

  • Live dashboard
  • Audit report (Word)
  • Executive summary (Word)
  • Excel workbook
  • PowerPoint presentation
  • Conference poster
  • ARCP evidence summary

Governance notes

  • Designed to use anonymised or pseudonymised audit identifiers.
  • This tool supports, but does not replace, clinical judgement.
  • Local policy, formulary and specialist advice should be followed.
  • Organisations remain responsible for local governance arrangements.
  • Risk assessment tools must not be used to predict future suicide or self-harm, or to determine access to care (NICE NG225).
  • Use anonymous case identifiers only — never patient-identifiable information.

Lazomis QI supporting resources