How do you write a progress note for self-harm?

Record each episode since the last session (date, method, body area, severity and medical care), the client’s intent during the act, urges and skills used, your suicide risk assessment, access to means, the intervention used and the updated safety plan, then the next session.

What is the ICD-10 code for self-harm?

In ICD-10-CM, R45.88 is used for current nonsuicidal self-harm and Z91.52 for a personal history of nonsuicidal self-harm. Injuries themselves are coded separately by the treating medical provider. Check your payer’s rules before billing with these codes.

Is self-harm the same as a suicide attempt?

No. Non-suicidal self-injury is done without intent to die, while a suicide attempt involves some intent to die. The same client can have both, and NSSI is a known risk factor for later suicide attempts, so ask about intent during each episode.

Should therapists look at self-harm wounds?

Usually not. Record what the client reports and who, if anyone, assessed the injury. If a wound is deep, keeps bleeding or shows signs of infection, the client needs medical care; for heavy bleeding or other emergencies, call 911.

How often should self-harm be reassessed?

Ask about self-injury and suicidal thoughts at every session while self-harm is a treatment focus, and sooner if the client reports a new method, more severe injury, increased frequency or suicidal thoughts.

Progress Notes for Self-Harm: Example and Template

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Overview

This guide is part of our complete progress notes hub — format structure, a full clinical example, the progress note generator, and all 72 diagnosis-specific templates.

No sign-up needed: open a fictional note in the MentalNote editor and edit it like a real draft.

Short answer: a self-harm progress note records each episode since the last session (date, method, body area, severity and any medical care), what the client was trying to do (for example, to stop overwhelming feelings, or to die), urges and the skills tried, your suicide risk assessment, access to the method used and to other lethal means, the intervention you used, and the updated safety plan.

Non-suicidal self-injury (NSSI) is deliberate damage to the body without intent to die, such as cutting, burning or hitting. Ask about intent during each act rather than assuming it, because the same person can have both non-suicidal self-injury and suicidal thoughts, and NSSI is a known risk factor for later suicide attempts. In ICD-10-CM, R45.88 (nonsuicidal self-harm) records current NSSI and Z91.52 a personal history of it.

What to document in a self-harm progress note

What to document in a self-harm progress note, with fictional example wording
Area	What to document	Example wording
Episodes	Date, method, body area, severity, frequency compared with before	“One episode of superficial cutting to the left thigh on Saturday (3 last week, 1 this week).”
Medical care	Who assessed the injury, and when	“Client reports the cut did not need stitches and is healing; not examined by the therapist; advised medical review if signs of infection.”
Intent and function	Intent to die during the act; what it did for the client	“Denied intent to die during the episode; described it as a way to stop feeling numb after an argument.”
Urges and skills	Peak and current urge, skills tried and what helped	“Peak urge 8/10, current 2/10; used ice and paced breathing twice before the urge passed.”
Risk and means	Suicide risk assessment, access to the method used and other lethal means	“Denied suicidal thoughts, plan or intent; agreed to keep blades out of the apartment; no firearms.”
Plan	Safety plan changes, homework, next session	“Added the new trigger to the safety plan; diary card daily; next session in 1 week.”

Describe injuries in neutral, specific terms and say who assessed them. A therapist usually does not examine wounds; if a cut is deep, keeps bleeding, shows signs of infection or a burn is large, the client needs medical care, and for heavy bleeding or other emergencies, call 911. If the client has taken an overdose or swallowed something harmful, treat it as an emergency even if they feel well. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means, protective factors, your risk formulation and the safety plan. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.

How to Document Progress Notes for Non-Suicidal Self-Injury

Session Summary

Overview of session focus, topics discussed, and client presentation

When documenting the Session Summary for self harm, focus on capturing the client’s reported symptoms, presenting concerns related to self injurious behaviors, identified triggers, and observed mood or affect throughout the session.

Document specific self harm behaviors reported since the last session, including frequency and methods used.
Note any identified emotional or environmental triggers discussed by the client.
Record the client’s current mood and affect, emphasizing fluctuations related to self harm thoughts or urges.
Summarize any recent stressors or events that may have contributed to self harm ideation.
Include any expressions of intent or safety concerns communicated by the client.

Interventions

Therapeutic techniques and interventions applied during the session

In the Interventions section, detail the clinical techniques and therapeutic modalities applied during the session that are specifically targeted toward managing or reducing self harm behaviors.

Describe use of safety planning strategies tailored to the client’s self harm risk.
Note any cognitive-behavioral techniques utilized to challenge self harm urges or distorted thoughts.
Document skills coaching provided, such as distress tolerance or emotional regulation exercises.
Record clinician observations of client’s engagement and affect during intervention delivery.
Indicate any psychoeducation offered regarding self harm triggers and coping alternatives.

Client Response

Client's reaction to interventions and observable progress

The Client Response section should capture the client’s reactions, progress, and clinical impressions related to self harm interventions and overall treatment engagement.

Evaluate the client’s verbal and nonverbal responses to safety planning and coping skills introduced.
Assess any reported changes in frequency or intensity of self harm urges since last session.
Note client insight into triggers and motivation for change regarding self harm behaviors.
Document any expressed ambivalence or resistance toward treatment recommendations.
Record clinical impressions related to risk level and diagnostic considerations based on session content.

Plan Updates

Changes to treatment plan, goals, and next session focus

In the Plan Updates section, outline the next steps in treatment, including any modifications to the current plan, homework assignments, referrals, and scheduling related to addressing self harm.

Specify any adjustments to safety plans or crisis intervention strategies.
Assign homework focused on skill practice aimed at reducing self harm urges.
Recommend referrals to higher levels of care or specialized services if risk escalates.
Update session frequency or modality based on client’s current self harm risk and engagement.
Plan for follow-up assessments to monitor self harm behaviors and treatment progress.