> ## Documentation Index
> Fetch the complete documentation index at: https://docs.getrivet.ca/llms.txt
> Use this file to discover all available pages before exploring further.
# How Rivet flags clinical risk
> PHQ-9 Item 9, C-SSRS items 4/5/6, and what Rivet surfaces during a measure — and what it does not do.
Some items on standardized measures carry weight beyond their contribution
to a total score. PHQ-9 Item 9 (suicidal ideation) is the canonical
example: a "nearly every day" answer is clinically significant regardless
of where the total lands. What follows is how Rivet surfaces those items
— and, more importantly, what Rivet does not do when they fire.
**Rivet does not auto-escalate.** No automatic text to a crisis line,
no message to a supervisor, no notification to an external service.
Clinical action — risk assessment, safety planning, escalation —
remains yours.
## What gets flagged
### PHQ-9 Item 9 — suicidal ideation
Item 9 reads:
> "Thoughts that you would be better off dead, or of hurting yourself in
> some way"
The published rule, from Kroenke 2001 forward, is that any non-zero answer
warrants suicide risk assessment regardless of the total PHQ-9 score. A
client with a PHQ-9 of 6 ("mild depression") and Item 9 = "several days"
needs the same Item 9 follow-up as a client with a PHQ-9 of 22.
The PHQ-9 template description in Rivet states this rule inline so it
appears in the "Copy for session notes" output and in the PDF download
alongside the response. The practitioner is the layer that reads the rule
and acts on it.
### C-SSRS items 4, 5, and 6
The Columbia Suicide Severity Rating Scale is a clinician-administered
measure. Rivet includes the Screening (Recent) variant with five ideation
severity items plus one behavior item. Three of these trigger a cutoff
the moment you answer YES:
* **Item 4** — active suicidal ideation with some intent to act, without
specific plan
* **Item 5** — active suicidal ideation with specific plan and intent
* **Item 6** — past 3-month suicidal behavior (actual / aborted /
interrupted attempts / preparatory acts)
When you (the rater) answer YES on any of items 4, 5, or 6, the
corresponding cutoff fires. It surfaces inline in your practitioner
view as a high-risk flag and in the score block as a labelled cutoff
message:
* Items 4–5: "Any YES on items 4 (intent) or 5 (plan) — high-risk;
immediate safety planning + means restriction indicated"
* Item 6: "YES on past-3-month suicidal behavior — high-risk; emergency
evaluation indicated"
The exact label text is what the C-SSRS literature uses; Rivet renders it
verbatim.
### Other sensitive items, by measure
A number of other items across the library are flagged as sensitive and
surface inside the score block when they fire:
* **EPDS Item 10** — self-harm in the postnatal context
* **CES-D-R Items 14 + 15** — death wishes / self-harm
* **QIDS-SR Item 12** — suicidal ideation
* **CPSS-5 Items 9, 10, 16** — trauma-related self-harm / suicidality
* **BSL-23 Items 5, 7, 12, 18** — self-harm / suicide subscale
* **ASQ — all 5 items** — NIMH suicide screen (positive on items 1–4 =
positive screen; item 5 YES = acute risk)
* **All 10 ACE items** — childhood adversity (handled with the same
sensitivity flag for trauma-informed UX)
For each of these, the published rule and the cutoff text from the source
paper are embedded in the template. Rivet shows the rule; the practitioner
takes the clinical action.
## What Rivet does on a flag
Concretely:
* The cutoff appears in your practitioner view as the measure is filled
* The cutoff appears in the score block of the "Copy for session notes"
output (e.g. `[Any YES on items 4 (intent) or 5 (plan) — high-risk;
immediate safety planning + means restriction indicated]`)
* The cutoff appears in the PDF download
That's the entire surface.
## What Rivet does not do on a flag
**No automatic crisis-line dial.** Rivet does not send a text or open
a call to a crisis line, a hotline, or 911 when a high-risk item fires.
**No automatic notification.** Rivet does not message a supervisor, a
consulting clinician, a partner practice, or anyone outside the
session.
**No automatic chart write.** Rivet does not write to your EHR,
flag a chart in Jane or Owl, or escalate a record into a triage
workflow.
**No automatic safety-plan open.** Rivet does not auto-launch the
Safety plan template when PHQ-9 Item 9 or a C-SSRS cutoff fires. That
remains your decision.
Clinical judgment + clinical action are yours.
This is a deliberate design choice. Auto-escalation in clinical contexts
can fire at clinically inappropriate moments, pathologize normal-range
responses (e.g. a "several days" PHQ-9 Item 9 in a long-stable client),
or interrupt a session at exactly the wrong therapeutic moment. The
practitioner's judgment is the right interpretation layer.
What Rivet provides is structured detection — the item is captured, the
cutoff is computed, the flag is surfaced inline and in your record.
What to do about it is the practice of psychotherapy.
## What pairs well with risk flagging
For positive ideation screens (PHQ-9 Item 9 > 0; C-SSRS item 4 or 5 YES),
the natural follow-on is a structured safety plan. The Rivet library
includes the **Safety plan** template — a 6-step crisis safety plan
based on the Stanley-Brown method. You can open it directly after a
flag fires, fill it collaboratively with the client during the same
session, and export it the same way (Copy for session notes, or
Download as PDF) so the safety plan goes home in writing.
A typical flow:
Item 9 > 0 on PHQ-9; or items 4/5/6 YES on C-SSRS.
Don't abandon mid-fill — the score block + cutoff text are what land
in your record. Finish, copy, and close.
From the Templates picker, pick **Safety plan**. The template walks
through warning signs → internal coping → social distractions →
people for help → professionals + agencies → means safety.
The client fills warning signs, coping strategies, contacts; you
annotate where relevant. Click "Download" for a PDF the client can
keep on their phone.
Risk assessment, escalation, after-session contact, supervisor
consultation — Rivet doesn't do any of these automatically. Rivet
captures the structured data; you decide what comes next.
For information on what's covered in the Safety plan template, see
Crisis → [Safety plan](/clinical-templates/crisis/safety-plan) in the
Clinical templates section.
## Related articles
The full scope of what Rivet does — and doesn't — around outcome
measures.
The 6-step crisis safety plan template that pairs with positive
suicide screens.
The collaborative fill flow that surfaces these flags in front of
you while you can still talk about them.