Hi Guys/Girls...Welcome to Psych!
As far as assessment, after vitals, I think the number 1 thing to evaluate is your patient's risk for suicide or homocide or assault within your facility. You can assess up and down physical stuff, but if you find a patient hanging in the bathroom, none of that will do you much good. Which brings me to my second point. During assessment, did the admit team search for contraband? Did they miss anything, like shoelaces? Check pockets?
Also skin assessments are important. Note any bruises, track marks, etc. Please don't do the skin assessment alone. Have another staff member of the same sex of the patient in there with you. If your patient is coming from jail, be aware that he or she is likely to have been exposed to TB, Hepatitis, etc. Does the patient appear to be responding to internal stimuli? Paranoia? Sexually inappropriate behaviour? Potential to elope? Make note of any threats the pt may make toward people 'outside'. We are obliged by Tarasoff Law under the Duty to Warn statute if we become aware that a pt intends to harm another person. I like to ask the pt what helps them de-escalate if he or she becomes agitated. Do they not like to be touched? Don't like people in uniform
? Does music help? What chronic health conditions do they have that may put them in danger if they get upset (i.e., hypertension, asthma)?
I'm sure I'm forgetting a bunch of stuff, but that's all I can think of right now. Good luck!