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Lethal means safety is an effective suicide prevention strategy with demonstrated results at the population level, yet individual-level uptake is less well understood. Using automated data extraction methods, we conducted an investigation of electronic health records from psychiatric emergency service (PES) patients from January 1, 2012 to December 31, 2017 at a busy urban medical center in the Pacific Northwest. At each PES mental health evaluation, every patient received a Suicide Risk Assessment during which providers used an electronic template with standardized fields to record lethal means access and other suicide risk factors. We assessed 32,658 records belonging to 15,652 patients. Among all visits, 69.9% ( n  = 22,824) had some documentation of lethal means assessment. However, 54.1% ( n  = 17,674) of all visits lacked some or all potential documentation detail. Additionally, among 59.6% of visits in which a patient had documented access to lethal means, the specific means available were not indicated. Across the twenty risk and demographic factors we assessed, the prevalence of documentation did not vary by any given risk factor and only varied minimally by age and race. For example, when comparing visits which indicated family history of suicide to those which indicated no family history of suicide, the prevalence ratio was 0.99 (95% CI: 0.95, 1.03). Despite the high-risk patient population, mental health focus of the facility, and the presence of a standardized tool, lethal means documentation was suboptimal. In alignment with recent recommendations, our findings indicate that additional focus on implementation is needed to improve documentation of lethal means assessment.HighlightsFifteen times larger than prior comparable studiesFindings demonstrate persistent under-documentation patterns in new setting and regionStandardized methods likely needed to improve documentation detail and frequency Fifteen times larger than prior comparable studies Findings demonstrate persistent under-documentation patterns in new setting and region Standardized methods likely needed to improve documentation detail and frequency

Lethal Means Assessment in Psychiatric Emergency Services: Frequency and Characteristics of Assessment