Mental Health Risk Assessment Documentation Audit

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.

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

• 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

• 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

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

• 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.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLinking Clinical Audit Findings to Organisational Risk ManagementThis resource guides NHS clinicians and teams on effectively linking clinical audit findings to organisational risk management processes, ensuring that identified quality gaps translate into meaningful risk mitigation strategies and sustained improvements. It provides a practical framework for risk scoring, escalation, and action planning.
• Digital Health and AIEnsuring Clinical Safety in AI-Driven Healthcare: A Practical Guide for NHS TeamsThis guide provides NHS clinical and digital teams with a practical framework for ensuring clinical safety when implementing and using Artificial Intelligence (AI) technologies in healthcare settings. It covers essential governance, regulatory considerations, and practical steps to mitigate risks.
• Clinical GovernanceLeveraging Risk Registers for Effective NHS Improvement WorkThis guide explores how NHS risk registers are not just compliance documents, but crucial catalysts for identifying, prioritising, and driving meaningful improvement work within healthcare settings. It provides practical insights for clinicians and leaders.
• Digital Health and AINavigating the New Frontier: Understanding and Mitigating Risks of AI-Generated Clinical Content in the NHSThis guide provides a comprehensive overview of the potential risks associated with using AI-generated clinical content within the NHS, offering practical insights and mitigation strategies for safe and ethical implementation.