Charting on psych patients

Specialties Psychiatric

Updated:   Published

Need help charting on psych patients. Basically I know what to chart about I just need help with the terminology. Can someone give me examples of terms or phrases used to describe different moods, thoughts and behaviors? I have looked something's up and it just gives me a vague definition. Help! New psych nurse here

Specializes in Psych.

Which ones are you not sure about?

Specializes in Psychiatry, Mental Health.
Which ones are you not sure about?

In addition, you can describe a situation or an observation and tell us how you think it should be charted. Your question is far too vague for us to help you.

Specializes in Psych ICU, addictions.

Here's some AN threads that may help you:

https://allnurses.com/psychiatric-nursing/psych-charting-255388.html

https://allnurses.com/psychiatric-nursing/i-seriously-need-370599.html

https://allnurses.com/psychiatric-nursing/need-help-charting-520221.html

And I agree with the other posters: if you can give us the specific terms/phrases/situations you are not sure about, we can elaborate.

Specializes in Outpatient Psychiatry.

I have a phone app with a psychiatric dictionary of sorts in it. It's not a professional app, but it helps with words "normal nurses" (lol) don't always use like akathisia, coprolalia, word-salad, and such. I'm not sure if this is the kind of help you're looking for. Oh, and the app, Psychiatry Dictionary, is in the Google Play Store.

Specializes in Psych Nurse.

This is exactly what I am struggling with right now. More experienced nurses use psych terms effectively. 

like labile, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, self-contemptuous, frightened, and perplexed.

Specializes in Emergency Medicine/Trauma/Psych/Private Duty/Peds.

Not sure exactly what you are asking for?...

Are you asking for the terms themselves or an explanation of the terms?

If you are looking for an explanation I would reference your physical assessment book as this would give a full description for such terms.

If it helps with documentation....for each pt I always list the below:

Document current activity: ie-sleeping, sitting on edge of bed, interacting with peers or activities, posturing

Affect: labile, flat, restricted, blunted, full range

Mood: sad, happy, excited, manic, elated, angry, enraged, hopeless, grandiose

Speech: pressured, flow, rapid, organized, disorganized, incoherent, mumbled

Thought process/content: disorganized, tangential, loose assoc, delusional, organized

Dress: disheveled, clean, neat, appropriate

Food: consumed

Sleep: # hrs.

Suicidal: y/n with plan or without

AV hallucinations with or without command

 

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