NR 668 Week 6 Safety Decision Write-Up Example

Safety Decision Write-Up: Active Thoughts of Overdose in Week Four of Treatment for Bipolar II Depression, and the Decision to Continue Outpatient Care

Student Name

College of Nursing, Chamberlain University

NR 668: Psychiatric-Mental Health Capstone Practicum & Intensive

Instructor Name

Month Day, Year

Safety Decision Write-Up: Active Thoughts of Overdose in Week Four of Treatment for Bipolar II Depression, and the Decision to Continue Outpatient Care

The Moment, Fixed and Sourced

30 September 2026, 15:10, a scheduled follow-up visit in week 4 of treatment. The patient, in the depressive phase of bipolar II disorder with recent mixed features, on quetiapine 300 mg at bedtime since 6 September.

Known at that point, and from whom. From the patient: after an argument with their partner the previous evening, they had thought for the first time about taking "all the quetiapine" and had looked at the bottle, but did not open it. They said they did not intend to do it and could not say why they had looked. They had drunk four beers that evening. From the partner, by phone with the patient's consent at 15:35: the argument was about money; the patient went to bed after the argument and the partner did not notice anything unusual; the medication bottle had been in the bathroom cabinet, not with the partner as agreed at the start. From the record: no prior attempts, PHQ-9 13 today, down from 19.

Not known, and could not be known: whether the patient would have acted if the partner had not been home.

The Assessment, as Reasoning

Columbia screen today: active ideation with a method in mind, no intent, no plan beyond the thought, one preparatory-like behavior (looking at the bottle), no attempt (Posner et al., 2011).

Concerning features, weighed: a new method thought involving the prescribed medication, which is lethal in overdose and was not secured; alcohol that evening; a mixed-feature illness; a family history of suicide; the trigger, a relationship conflict, is likely to recur. The method and access weigh most, because they are specific and changeable.

Protective features, weighed: no intent stated, and the patient raised the event themselves at the start of the visit; mood improving on the PHQ-9; the partner engaged and reachable; the child named as a reason to live; no firearms; the patient asked for help with the medication storage.

The Decision

Continue outpatient care. Do not arrange emergency evaluation or admission today.

The patient is not at imminent risk: there is no intent, the method can be removed, and the patient and partner are engaged. Admission would disrupt work and childcare, weakening protective factors, without addressing the specific risk, which is access to a stockpile of quetiapine and alcohol.

What Was Done

Lethal means: from today, quetiapine prescribed in one-week supplies, held by the partner and given nightly, with the old bottle returned to the pharmacy for disposal that evening. The partner agreed by phone.

Safety plan revised with the patient, adding the argument as a warning sign, alcohol as a risk to avoid, and a step to leave the house for a walk and call a named friend before reaching for anything (Stanley & Brown, 2012).

Alcohol: the patient agreed to stop drinking until the next visit.

Follow-up: telephone call in 48 hours, in-person visit in one week rather than two. In a large emergency department study, patients who received a safety plan plus follow-up calls had less suicidal behavior afterward (Stanley et al., 2018), and the follow-up call follows that model.

Who Was Told What

The patient: the decision, the reasons and the changes, in plain words.

The partner, with consent: the medication arrangement and the follow-up plan; not the content of the session beyond what the patient agreed to share.

The supervising nurse practitioner: the full assessment, at 16:00; agreed with the decision.

Primary care: a letter the next day describing the medication change.

What Would Reopen It

Any statement of intent; any plan with a time or place; any further preparatory behavior, such as gathering pills from elsewhere; heavy drinking; the partner reporting that the medication arrangement has broken down; or the patient missing the 48-hour call. Any of these would prompt same-day reassessment and consideration of emergency evaluation.

Why Not Emergency Evaluation

An emergency department visit would have been reasonable if the patient had expressed intent, could not agree to the medication arrangement or had no one at home. None applied. An emergency visit would also have meant hours away from the child and work, and a likely discharge the same night with the same bottle at home. The specific risk, an unsecured supply of a medication dangerous in overdose plus alcohol, was better addressed directly.

What I Considered and Rejected

Stopping quetiapine altogether: rejected, because the patient's mood and sleep were improving and stopping would risk a return of the mixed state. Switching to a medication less dangerous in overdose: considered for the 12-week review, when lamotrigine would be discussed anyway, not today, since a change in the middle of a crisis adds instability. Increasing visit frequency to twice a week: offered, since some patients find a closer schedule reassuring; the patient preferred the 48-hour call and the one-week visit, which was acceptable given the protective factors.

How the Assessment Was Structured

The Columbia screen gave the structure for asking about ideation, method, intent, plan and behavior in the same order every time, so that today's answers can be compared with those at the first visit (Posner et al., 2011). The safety plan gave the structure for the response. The clinical reasoning, which features weighed most and why, is what neither tool supplies, because tools describe risk without deciding what to do about it, and it is written out above so that a reader can see where judgment entered.

Documentation

The assessment, the decision, the reasoning, the people told and the triggers for reassessment were recorded in the note the same afternoon, with the Columbia screen results and the revised safety plan scanned into the record. A copy of the safety plan went home with the patient, and a second copy, at the patient's request, with the partner.

What Happened Next

The 48-hour call was answered; no further thoughts of overdose, no alcohol. At the one-week visit the Columbia screen was back to passive ideation only. The partner reported giving the medication nightly without difficulty, and the patient had not drunk alcohol since the visit. The arrangement continued through the end of the term, and the partner said it had become an ordinary part of the evening routine rather than a reminder of the crisis.

References

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277. https://doi.org/10.1176/appi.ajp.2011.10111704

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776