Charting

[red2003xlt, LPN]

Hello All,

I'm a LPN working in a Cris Stabilization Unit of a Psychiatric Hospital. The clients are primarily low/no income street people who rotate in and out usually due to non-complaince with medications.

Heres my question, what should I chart? As the LPN I primarily handle the med pass, transcribe doc orders, and give ETO's (aka the booty shot).

My charting consists of part med compliance and then a note about sleeping (work overnights). I think I'm missing something.

Are there any data points that should be noted with every entry?

Thanks in advance

[Meriwhen, ASN, BSN, MSN, RN]

It should be no different than what you'd chart in any other nursing setting: subjective and objective data and interventions (if any) that are done.

What's the patient's mental status (AOx4 or otherwise)? What did you talk to the patient about? Were they compliant with their meds? Any med ed given (scopes of practice aside, IMO a LVN better damn well be able to explain the medication they are administering or they shouldn't be administering it in the first place). If the booty shot was needed, why? Is the patient meal compliant? Behavior in the milieu? Attending groups/activities? Playing well with others? Vital signs WNL? Any concerns on either your or their part? And did you have to bring any of these concerns to a RN's attention?

You don't always have to address all of these...pick and choose what is applicable to your patient, your shift and your duties. ALWAYS address SI, HI, unsafe behavior and psychosis regardless, even if it's just "patient denies SI" or "none observed or reported."

Since it's an overnight shift, they will be resting for a lot of it...and if they're resting, you can't help that :)

Oh yeah: the patient is NEVER sleeping...because how can you concretely prove that just by observation? A safer CYA wording is "patient resting in bed quietly with eyes closed."

Hope this helps a bit!

[red2003xlt, LPN]

Thanks, it does help

[ruhzdyn]

Hey "Red". I understand your dilemma. I used to work on an observation unit aka crisis unit. Although I'm an RN-BC, my notes at the very least consisted of the following.

Mood- (stated mood), Affect- (Euthymic?), Speech- Regular Rate/Tone/Volume (pressured, latent, etc)

Thought Process- (delusional, paranoid, thought blocking, etc.) Gait- (steady?)

client denies SI/HI/HALLUCINATIONS. (If hallucinations are present, I usually will state "command type" "paranoid type" "persecutory type). Client denies pain at this time. (if pain is present, location, blunt/sharp, intensity, factors making it worse or better).

Interventions provided include- therapeutic communication, medication administration, promotion of therapeutic goals, with observation at 15 minute intervals for safety (tailor as needed). Post intervention assessment included client now calm and states feeling in control of mood.

Of course this is very basic. Off the top of my head, my notes would look like that in general. Hope it helps!

[red2003xlt, LPN]

Thanks bunch, especially as I've been to an afternoon shift with much client interaction