What the patient thinks about. Delusions, obsessions, suicidal/homicidal thoughts, preoccupations — content is where pathology becomes specific.
Encounter card
Setting
Throughout the encounter, with targeted screening questions for high-risk content (suicidality, homicidality, psychosis).
Opening move
Note spontaneous content. Then ask direct, non-leading screening questions for high-risk content: SI/HI/AVH/delusions. Direct questions about hard content don't make patients more likely to act — they make them more likely to disclose.
Sample language
"Sometimes people in your situation have thoughts of hurting themselves. Are you having any thoughts like that?"
"Have you been hearing voices or sounds that others around you can't hear?"
"Do you ever feel like others can read your mind or are trying to harm you?"
Avoiding direct questions about suicidality from fear of "putting ideas in their head" (no evidence this happens; substantial evidence it doesn't). Accepting "no" without follow-up when affect or context suggests otherwise. Not distinguishing passive ("I wish I weren't here") from active ("I'm thinking of overdosing") suicidality.
Red flags / escalate: Active suicidality with plan/intent/means. Command hallucinations to harm self or others. Homicidal ideation with specific target. Newly emerging psychosis. Persecutory delusions with belief that target person is the clinician.
Documentation
Direct quotes when content is specific. Document SI/HI/AVH explicitly (denies/endorses with details). Document delusions as the patient describes them, not as your interpretation.
Real-world reality: Suicide and homicide risk screening must be documented specifically in chart — the boilerplate "denies SI/HI" can be argued as inadequate documentation if outcomes are reviewed. Specific findings about content, intent, plan, means are protective both clinically and legally.
Screening for high-risk content is mandatory in every psychiatric encounter. Ask directly. Document explicitly.
Warm grey-tinted clinical notebook page, slate gray accent. Mandatory screening items — SI, HI, AVH, delusions. Margin clusters on direct vs leading questions.
Thought content is what the patient thinks about. Where thought process is about structure, content is about substance — preoccupations, ideation, delusions, hallucinations, themes. Screening for high-risk content is mandatory in every psychiatric encounter, regardless of presenting complaint.
The mandatory screen: suicidal ideation, homicidal ideation, auditory or other hallucinations, delusions. Each in every encounter. The patient who didn't volunteer suicidal thoughts may have them; asking is how you find out. Asking direct questions about suicide does not create suicide. The substantial evidence on this point is clear: direct, non-leading questions facilitate disclosure of existing ideation; they do not implant it.
Hierarchy for suicidality: passive ideation ("I sometimes wish I weren't here") → active ideation ("I'm thinking about killing myself") → plan ("I've been thinking how I would do it") → intent ("I've been thinking about doing it") → access to means → preparation. Each level changes management. The patient with passive ideation and intact protective factors may be safe outpatient with safety planning; the patient with active plan, intent, and means access is in a different clinical situation.
Delusions deserve specific exploration. Type — paranoid (someone is harming me), grandiose (I have special powers/identity), somatic (something is wrong with my body), referential (events refer to me specifically), jealous (my partner is unfaithful), erotomanic (someone famous loves me). Conviction strength — fixed belief vs. uncertainty. Insight — can the patient consider the possibility they're wrong? Functional impact — does the belief drive behavior?
For auditory hallucinations, screen specifically for command hallucinations to harm self or others. These are high-risk content. "Are the voices telling you to do anything?" The patient who has been hearing voices for years often doesn't volunteer the command content until asked.
Quote specific content in your documentation. The patient's exact description of the delusion or the threat preserves nuance the clinical summary loses. "Patient states: 'I'm being followed by people in cars when I leave my apartment.'" Better than "patient endorses persecutory delusion."
Suicidality dimensions — passive, active, plan, intent, means, timeline, history. Margin notes on each dimension.
The anchor
Thought content is what the patient thinks about. Screen directly for high-risk content (SI, HI, AVH, delusions) in every encounter. Direct questions disclose pathology; they don't create it.
Common delusion types — paranoid, grandiose, somatic, referential, jealous, erotomanic. Margin clusters on how each presents and questions to elicit.
Prove it
A new patient with a history of depression denies suicidal ideation when asked directly. Their affect is constricted, they recently lost their job, and they describe feeling "like a burden." How do you proceed?