Recording exact words, actions and handover

Notes made after contact about self-harm or suicide risk should allow another staff member or clinician to understand what was said, how the contact happened and what action was taken.

Why vague records are unsafe

Words like "upset", "mental health issue" or "wants advice" can conceal the seriousness of a contact. A clinician, call handler or out-of-hours service needs to know whether the person mentioned self-harm, overdose, suicidal thoughts, a plan, access to means or an inability to stay safe.

Records do not need to be long, but they must be specific. The safest note preserves the person's own words, records the time and route of contact, and shows who accepted responsibility for follow-up.

Record

• Exact words, using quotation marks where possible.
• Time and contact method, including phone, desk, online request, third-party call or message.
• Any stated self-harm, overdose, plan, intent, access to means or immediate danger.
• Location and call-back details if available.
• Who was informed, when and what happened next.
• Failed contact, refusal, disconnection or uncertainty.

Make handover usable

A safe handover lets someone who did not hear the original contact understand why it is urgent. For example: "Patient said, 'I have taken extra tablets and feel sleepy', call at 16:45, address confirmed, duty GP interrupted, 999 route used" is far clearer than "mental health call".

When another person reports concern, record who called, their relationship to the patient, what they said and what action you took. Do not include unnecessary opinion or speculation.

Handover

"Upset again" is not an adequate record when self-harm or suicide risk has been mentioned.