Prior work from surveys and limited populations suggests many emergency department (ED) patients with suicide risk do not have documented lethal means assessments (e.g., being asked about home firearms). The specific objectives of this study were to, in an ED with universal screening for suicide risk: (1) estimate how often ED providers documented lethal means assessment for suicidal patients, and (2) compare patients with and without documented lethal means assessments. We reviewed 800 total charts from a random sample of adults in three a priori age groups (18-34 years; 35-59 years; > /= 60 years) with a positive suicide risk screen from 8/2014 to 12/2015. Only 18% (n = 145) had documentation by > /= 1 provider of assessment of lethal means access. Among these 145, only 8% (n = 11) had documentation that someone discussed an action plan to reduce access (most commonly changing home storage or moving objects out of the home). Among 545 suicidal patients discharged home from the ED, 85% had no documentation that any provider assessed access to lethal means. Our findings highlight an important area for improving care: routine, documented lethal means assessment and counseling for patients with suicide risk. There is an urgent need for further exploration of barriers and facilitators.