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P200 Suicide Risk Assessment According to Best Practice Guidelines: The Development of a Chart Audit Performance Measure
  1. E Santa Mina1,
  2. C O’Grady2,
  3. E McCay1
  1. 1Ryerson University, Toronto, Canada
  2. 2Centre for Addiction and Mental Health, Toronto, Canada
  3. 3Ryerson University, Toronto, Canada


Background Best practice guidelines (BPGs) in suicide risk assessment documentation support nursing care of clients at risk for suicide. Investigation regarding nurses’ adherence to BPGs for suicide risk assessment documentation is minimal.

Objectives In a mixed-methods study to investigate nurses’ knowledge of suicide risk assessment documentation, the researchers created a chart audit to measure nursing practice congruence with five recommendations from the suicide risk assessment BPG (RNAO, 2009).

Methods Five recommendations, from the BPG: Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour (RNAO, 2009), were the benchmarks for the chart audit measure. Suicide risk indicators, as determined by the Minimum Data Set for Mental Health (MDS-MH) (Ontario Ministry of Health, 2011), were the criteria to identify charts of suicidal clients. The researchers integrated MDS-MH indicators with the five BPG recommendations and constructed compliance indicators that incorporated the Nurses Global Assessment of Suicide Risk (Cutcliffe & Barker, 2004).

Results Five BPG recommendations, integrated with provincial suicide assessment criteria and a standardised suicide assessment scale produced a 3-point likert scale chart audit with 15 indicators. Possible ranges of scores for documentation congruence with the BPG are 0 to 30.

Discussion This performance measure provides objective, proxy data to triangulate with nurses’ self-perception of suicide risk documentation and evaluate practice as per BPGs.

Implications for Guideline Developers/Users A standardised instrument to monitor BPG practices can be used to inform implementation and education strategies.

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