Psychiatric home care notes

  1. Hi, I have just started a per diem job doing home visits for psych pt's. I assess mental status, mood, give meds, etc, I have to document for continued home care. Can someone show me a generic care note example. I know I have to use words like at risk for decompensation without sn care. I would like to be a little more professional with my notes than what I am presently doing. Thanks for any help,
  2. Visit djasset profile page

    About djasset

    Joined: Jan '06; Posts: 17


  3. by   mentalhealthRN
    my guess is you have never worked as a psych nurse prior to this job?? Did you not have a psych rotation in school. This is exactly why a nurse who has never worked psych should not be "learning" in an isolated environment. You should have recieved training from the company that hired you on. That they didn't leads me to believe that they assume you know what you are doing. Let me give you an example. When I first started my first FT psych job inpatient we had a CNS in psych who was the educator for the unit and we had to spend 8 hours a day with her for two weeks before we hit the unit. She reviewed all the common psych dx, common behaviors and management of the them. De-escalation techniques--verbal. She reviewed how to do a mental status exam as we did them every shift. She talked about general documentation. We had a couple of days of training for managing the violent pt when de-escalation is not successful to keep you and the pt safe. This is what your company should be teaching you so you know what the heck you are doing. So sorry if my note sounds harsh--don't mean it to. Just being honest with you and also pointing out that your campany is at huge fault for not providing you the proper training and you deserve to get that training. By sending you in there like it sounds like you are I just worry that this is a set up for failure and for you possibly getting hurt. And that is not fair to you.
  4. by   djasset
    Hello Mental Health RN.

    I appreciate your response and concern for my well being. As I am sure you are aware, anyone dealing with psych patients is at risk, regardless of experience or training. To clarify, I did have a psych rotation in nursing school. I have 3 years ED experience dealing with psych patients and have been trained in de-escalating. I also have experience in the hospital taking care of patients with psych diagnosis. That being said, my question was not about how to take care of this patient population, but how to be more professional in my documentation of home visits. My hat is off to you for taking care of this population for 7 years. I know that personally, as a full time career, it is not my forte!

    Again, thank you for taking the time to respond.
  5. by   mentalhealthRN
    Well it sounds like you should be good with caring for them-- again I always just worry about safety. As far as notes.....Do you actually have to do a mental health eval? a lethality assessment? I would find out from your agency what they require to start with. They may expect you to do that or not want you to....hard to say. Are you there specifically for their psych dx? or for medical?
    What I would do is a basic eval just to document: mood, affect, any reported or observed signs of A/V hallucinations, any delusional thinking, thought process, any SI or HI, motor function (psychomotor agitation, etc.), speech pattern, INSIGHT and JUDGEMENT probably important as a lack of either or both could support need for continued support. Also important might be to discuss what supports the ct does have as lack of supports (family, friends, community programs, etc) would also support need for continued support. A mention of the cts ability to keep up with ADLs/IADLs or not could help in supporting that need for continued care. Meds. If the ct has been med-compliant. Check the medi-set if they use one to note anything that could indicate need for more support with meds (ie-the pills all mixed up from the way you put them--looking like they dropped the box but didn't! lol) Compliant with treatment/psych appts? oh and Coping skills, safety plan, etc. can be mentioned when talking about support. Oh and last thought....document how the ct is tolerating meds....any side effects, EPS, etc. and a set of vitals. you can document sleep too, and if normal or any problems. If they are diabetic and on any of the second generation anti-psychotics-- you can note how the BGs have been, and I would do a weight occasionally and document it for these folks. Those meds can cause probs with weight and glucose levels. Some docs do HGA1C now and then on them to monitor.
    This is the kind thing that comes to mind--......I know its not in formal format but I hope this helps. If you need help with the mental health eval part there are a lot of books out there and probably stuff on line.
    But overall if you can support in your note that the ct continues to need support or assistance with things due to their chronic mental health dx and show why-evidence- you should be okay. Hope this was helpful. Good luck.
  6. by   nurseprettybetty
    I just searched nursing notes for psyche patients and came upon this thread. I am shocked at the response of mental healthrn. So unnecessary. That's a major issue in nursing today, that nurses are so judgmental and rude to others. Why write such a nasty response then apologize for sounding harsh? This MENTAL HEALTH RN must be BIPOLAR. I too like djasset was searching for help with proper documentation. I had a psyche rotation, a very enriching one at a forensics psyche facility, where all the patients had murdered someone. I also work chronic pain patients who the majority have psyche issues in addition to alcohol and narcotics withdrawal so I have psyche experience but I am now doing home visits with children and wanted to be sure I was charting properly! Sometimes I wonder how somebody can be so educated, yet so ignorant!
  7. by   paradiseboundRN
    Unfortunately, I'm seeing these type of bully replies more and more on this board. What ever happened to "there is no dumb question"? I hope people aren't going to be afraid to post. Most of us are caring and supportive.
  8. by   KarenJordan
    Document if mood is stable, presence of mania or depression. free of hallucination, delusions, suicidal ideation. why do they need services - h/o non-compliance, cognitive defecits. how does their illness affect their ADL performance? Do they require the services for redirection and guidance and ADL's. do they have problems with safety due to impulsivity or attention defectis? also document side effects of medication - do they have any EPS. are they following up with their psych md?
    Mental Health RN chill - home care is way different than institutional nursing!