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PS12.1 | Psychiatric Emergencies — Assignment
CLINICAL SCENARIO
This assignment develops your ability to perform and document a structured suicide risk assessment. Using a provided clinical vignette, you will conduct a systematic six-domain assessment, stratify risk, formulate a safety plan including means restriction, determine appropriate disposition, and produce a clinical documentation record that meets medico-legal standards. This mirrors the real-world clinical task you will perform as a physician regardless of specialty.
Instructions
Read the clinical vignette below carefully. Then complete all five sections of the structured assessment write-up as described in the scaffolding. Your response should read as a coherent clinical document — not a list of notes — that a senior clinician could use to make a management decision.
Clinical Vignette — Mr R.K., 48 years old, male:
Mr R.K. is a 48-year-old schoolteacher who presents to the emergency department at 11 pm brought by his wife. She found him in the garage with the door sealed and the car engine running, approximately 30 minutes before presentation. She states he has been withdrawn and not eating for the past three weeks since receiving news that he has been passed over for a long-awaited promotion. He has no prior psychiatric history. He was previously treated for hypertension and is prescribed amlodipine 5 mg daily (a one-month supply is in the bathroom cabinet). He denies any current intent but is tearful and uncommunicative. His wife states that his father died by suicide when Mr R.K. was 12 years old. He has two school-aged children and a close friend who called him daily until recently, when Mr R.K. stopped answering the phone.
You are the duty doctor performing the initial psychiatric assessment.
Length: 600-900 words
What to Submit
Section 1: Six-Domain Structured Assessment
Systematically document your findings across all six assessment domains in sequence: (1) Suicidal ideation — nature, frequency, duration, passive vs active; (2) Intent — degree of intent to act on ideation; (3) Plan — whether there is a specific method, and how specific and actionable the plan is; (4) Means and access — what means are available and how accessible they are; (5) Past attempts — any prior attempts, their lethality, and medical severity; (6) Protective factors — what is keeping the patient alive. For each domain, state both what was found in the vignette AND what you would clarify by direct inquiry, including the specific questions you would ask. You may not have all information from the vignette alone — explicitly note gaps that require direct questioning.
Section 2: Risk Factor Synthesis
List the risk-elevating factors present in this case (biological, psychological, social, situational) and the protective factors. Then write a structured paragraph synthesising these into an overall risk stratification (low / low-to-moderate / moderate / high / imminent). Justify your stratification with reference to the specific findings from Section 1. Note which single historical factor in this case carries the highest statistical weight.
Section 3: Safety Plan
Write a complete safety plan as you would document it in the medical record. Your safety plan must include: (a) a means restriction component — specify which means must be addressed and how; (b) at least two internal coping strategies the patient could use during a crisis before reaching out; (c) social contacts (with roles, not just names); (d) professional crisis contacts including a 24-hour option; (e) the agreed escalation pathway if the plan fails. Briefly explain why means restriction is the highest-priority structural component of this plan.
Section 4: Disposition and Legal Framework
Based on your risk stratification, state your disposition decision and justify it: outpatient with follow-up, day hospital, voluntary inpatient admission, or involuntary admission. Describe any immediate actions before transfer or discharge. Briefly address the legal framework applicable to this patient's care under the Mental Healthcare Act 2017 — specifically, how Section 115 applies here and what it obligates the treating team to do. Identify one common clinical error in disposition for this risk level and how you would avoid it.
Section 5: Clinical Documentation
Write a condensed clinical note (3–5 sentences) as it would appear in the patient's medical record following this assessment. It must include: the six domains assessed and key findings, the risk stratification assigned, the safety plan summary, the disposition decision, and follow-up arrangements. This note should satisfy medico-legal documentation standards — it should be legible to any physician reviewing the record subsequently.
Grading Rubric — Structured Suicide Risk Assessment — Marking Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Completeness and accuracy of the six-domain structured assessment | 10 pts | All six domains addressed in correct sequence, each with specific findings from the vignette AND explicit questions for gaps. Ideation, intent, plan, means/access, past attempts, and protective factors each receive substantive engagement. No domain omitted or conflated. |
| Risk stratification accuracy and justification | 10 pts | Correct risk level (high risk, given specific plan + means + family history of completed suicide by same sex parent + isolation + ongoing depressive episode). Justification names specific risk-elevating and protective factors. Correctly identifies prior attempt as the single strongest historical predictor (here: father's completed suicide is a risk factor, not an attempt — student must note this and ask explicitly about any personal prior attempts). |
| Safety plan quality — especially means restriction | 10 pts | Safety plan explicitly identifies BOTH lethal means in the vignette (carbon monoxide/car and one-month supply of amlodipine) and specifies a concrete restriction plan for each (e.g., transfer car key custody to wife, have wife hold/lock medication supply). Internal coping, social contacts, professional contacts, and escalation pathway all included. Explains that means restriction is the highest-priority structural element. |
| Disposition decision, MHCA 2017 application, and legal framework accuracy | 10 pts | Disposition is justified and appropriate to the risk level. MHCA 2017 Section 115 correctly described (presumed severe stress, not punished, State to provide care; supersedes IPC 309/Mental Health Act 1987). Correctly notes that Section 115 protects the patient from punishment and does not require certification of mental illness. Identifies one common disposition error (e.g., discharging a high-risk patient because they deny current intent) and avoidance strategy. |
| Clinical documentation quality and medico-legal adequacy | 10 pts | Clinical note is concise, complete, and medico-legally adequate. Contains: assessment domains with key findings, risk stratification, safety plan summary (including means restriction), disposition, and follow-up. Could be used without ambiguity by any subsequent clinician reviewing the record. |
PEER REVIEW
Review your peer's submission as if you are a senior clinician providing formative feedback before clinical rotation. For each of the five rubric criteria, note: (1) what the student did well — be specific; (2) one concrete gap or inaccuracy; (3) one suggestion to improve clinical quality or documentation standard. Do not simply assign a score — provide actionable written comments. Pay particular attention to: whether both means in the vignette were identified and restricted, whether MHCA 2017 Section 115 is accurately stated, and whether the risk stratification is justified with specific evidence from the assessment rather than generic statements.