PSY-SOP-001: Suicide risk screening and continuous observation

Standards › Standard 52 › Standard operating procedures (SOPs)

SOP · PSY-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 52.1

At a glance

Every psychiatric admission is screened for suicide risk with a validated tool (PSY-FRM-001).
A patient identified as high risk is placed on continuous observation, with each check recorded (PSY-REG-001).
Risk is reassessed at each change in condition and at least daily.
Observation is stepped down only by the responsible psychiatrist, with the reason recorded.
Stop and get help straight away if: a patient identified as high risk is not on continuous observation.

1. Purpose

To make sure every psychiatric patient is screened for suicide risk, and that high-risk patients are continuously observed (52.1).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

A person admitted to a psychiatric unit may be at risk of taking their own life. Screening every admission with a validated tool, and watching those at high risk, can prevent a death.

5. Responsibilities

Role	Responsibility	Competence
Responsible psychiatrist	Reviews the screen, sets the observation level and steps it down	Clinical lead
Nurse in charge	Carries out the continuous observation and records each check	Responsible psychiatrist

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Screen.

Screen on admission with the validated tool and record the result (PSY-FRM-001).

Key point: Screened.

Step 2. Observe.

Place a high-risk patient on continuous observation and record each check (PSY-REG-001).

Key point: Observed.

Step 3. Reassess.

Reassess risk at each change and at least daily, and step down only with the psychiatrist’s decision.

Key point: Reassessed.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Admissions screened on admission	100%	Monthly	Clinical lead	Escalate to the hospital director
High-risk patients on continuous observation	100%	Each shift	Nurse in charge	Escalate to the responsible psychiatrist at once

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
PSY-FRM-001	Suicide risk screening record	Record
PSY-REG-001	Continuous observation log	Register

17. Evidence

Reference	Note
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Psychiatry & Mental Health Accreditation Endorsement (AMB-20)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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