Psych charting - page 2

by crystalbrz 38,224 Views | 24 Comments

Recently, my facility is changing the format they require for nursing notes. If we can offer an alternative to their suggestions, we may get them to bite. Any suggestions on a effective format.?... Read More


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    The adult unit I work on uses SOAP charting. I personally like it. The Subjective portion is so important to psych charting as is the Objective portion. We also SOAP chart to the patient's treatment plan by picking a problem or goal off the treatment plan and addressing it in a SOAP note.
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    Our facility uses DAP notes. I find it takes some getting used to after writing narrative notes in med surge. Being new to psych, I have a question about charting. Is it appropriate to quote a patient's expletives if it is of some meaning. For example, a patient who is harrassing/threatening another patient and calls them a certain expletive. I'm thinking back on a note I wrote last evening and am hoping I did the right thing. I also stated in my note this patient felt afraid of the patient that swore at her due to the behavior of the aggressive pt and what we did about it/room change, ensured her safety and safety of unit, etc. I don't know why I'm doubting what I wrote now. I just don't feel I got a lot of training with regard to charting in psych (other than mental status exam). Thanks.
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    I don't think it's necessary to quote expletives unless they convey a bigger picture that saying something like "pt swore at peer, using threatening words". That being said, it's almost always better to quote rather than say something that might come off as subjective rather than objective.
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    no, none of us received much teaching re: charting in psych...I agree, you just learn as you go.....I always think it is a good idea to "quote" pts. remarks, especially if it helps to show their behavior or status...also helps doc to read the quotes, too...
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    I am in a psych ER now so don't have to deal with this any longer--thank god! But when I was on inpatient psych we had 10 patients each and they did a preprinted thing where you checked and circled, etc when I first started but people rushed they said and didnt chart accurately--I liked it......they changed then to SOAP and 10 soap notes is A LOT to write!!! Especially when its every single shift. I found that some patients I could write what was needed in a few sentances......the patient who did fine, took their meds and you did little for besides hand them their meds.....unfortuanely when you have 10 patients each the squeeky wheel gets the grease! So on a couple of patients you might have 2 pages worth of crap to write then the others you have to try to remember who the hell they even are!! LOL Thank god for wonderful techs! So I eventually said the hell with it I'm writing a narative and just be happy all 10 notes are done!! lol --seriously you have the patient you literally says four words all shift and behaves and what the hell do you write for subjective......"Thanks". (for the pills) and "when is lunch?" yeah I write that and well that is really worthe writing.... or reading!! LOL
    God I do not miss that stuff.......now I do the initial evals when they first get to the hospital. That is a short narative and the rest 6 pages of forms.
  6. 0
    Quote from psychRNinNY
    I am in a psych ER now so don't have to deal with this any longer--thank god! But when I was on inpatient psych we had 10 patients each and they did a preprinted thing where you checked and circled, etc when I first started but people rushed they said and didnt chart accurately--I liked it......they changed then to SOAP and 10 soap notes is A LOT to write!!! Especially when its every single shift. I found that some patients I could write what was needed in a few sentances......the patient who did fine, took their meds and you did little for besides hand them their meds.....unfortuanely when you have 10 patients each the squeeky wheel gets the grease! So on a couple of patients you might have 2 pages worth of crap to write then the others you have to try to remember who the hell they even are!! LOL Thank god for wonderful techs! So I eventually said the hell with it I'm writing a narative and just be happy all 10 notes are done!! lol --seriously you have the patient you literally says four words all shift and behaves and what the hell do you write for subjective......"Thanks". (for the pills) and "when is lunch?" yeah I write that and well that is really worthe writing.... or reading!! LOL
    God I do not miss that stuff.......now I do the initial evals when they first get to the hospital. That is a short narative and the rest 6 pages of forms.
    How 'bout charting on 25 pts.???? We have one nurse for up to 25, then 2 nurses for up to 40....
    Needless to say, my charting is slim.......unless there is a real problem to chart about....Ours is checks and circles but then you have to chart to address the treatment plan also......UGH !!!!
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    25 patients? In an acute care unit? Or is that more of a long-term psych facility? The ratios are different for acute care vs. long term aren't they? And you don't have to chart everyday in long term care I though......once a week is what I thought, of course if you have a patient that has something go on on a particular day or days you would have to chart that..........but. Maybe psych long term is different than medical long term. I never worked psych long term, only medical SNF/LTC. charting on and being responsible for 25 ACUTE psych patients can't be safe and I can't imagine OMH would okay that..........????
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    Quote from psychRNinNY
    25 patients? In an acute care unit? Or is that more of a long-term psych facility? The ratios are different for acute care vs. long term aren't they? And you don't have to chart everyday in long term care I though......once a week is what I thought, of course if you have a patient that has something go on on a particular day or days you would have to chart that..........but. Maybe psych long term is different than medical long term. I never worked psych long term, only medical SNF/LTC. charting on and being responsible for 25 ACUTE psych patients can't be safe and I can't imagine OMH would okay that..........????
    we are a private hospital...our pts. stay anywhere from 7 days to 4 weeks..(dep. on their ins. and needs)
    we chart q. day on all.....we usually have 3-4 MHT's so that helps a lot.....and a med nurse (LPN) that gives the meds.....so we basically do admits, groups, interview each and chart, attend tx. team meetings, etc. etc......
    some days OK, some are wild.......
  9. 0
    Wow, thats interesting. With the LOS you mentioned it sounds like an acute facility. Are you funded and monitored by OMH or no because you are private? So you have two nurses RN, LPN, and 4 techs --6 people for 25 and 7 for 40......hmmmm......interesting. So in numbers over all it isn't too much different then where I was --tough they were suppose to have 5 nurses for 30 and 2-3 techs but always ran on 3 nurses due to shortage. So even the charge had 10. You just have less nurses and more techs and in a restraint it doesnt matter much. But for charting and meds yuck!! You poor nurses. .................I find it interesting to see how other facilities run to see what is worse and what is better! LOL
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    no, sometimes only one RN if census is under 25....sometimes two...
    I have had 40 pts. with only 2 MHT's....if there are no 1 on 1's or LOS it is manageable....if we have 3 LOS and 1 one on one, it is tuff....once I got someone from housekeeping to do a LOS, we were desperate !!!

    3 nurses for 30....were they all RN's or was that counting the med nurse?

    yes, the charting is hellacious at times....


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