Psych charting - page 3
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
- 0Jun 24, '09 by WhisperaI can't give you an exact note, since you haven't given us much info, but here are some hints:
B = Behavior What is the child doing that would indicate a problem or an improvement in whatever the focus of treatment is?
I = Intervention What did you do or other staff members do about the behavior?
R = Response What was the child's response to what you or the other staff members did?
P = Plan What will you do next or what can you guarantee others will do next, to help with what you're charting about or to help the child improve?
- 0Jun 15, '10 by NCindasun21I'm in the same boat as Aloevera. Private hospital, 26 patients, acute, 1 RN, 1 LPN. We're being "encouraged" to change our documentation from a narrative of how they were doing (both positive and negative) to focusing just on behaviors that support their being in the hospital. I'm uncomfortable with this as it encourages "fudging" the report.
For example - a suicidal patient now contracts for safety, denies SI, participated in group and individual therapy, and is compliant with meds, etc. BUT it's only been 4 days since the attempt. How can you document that s/he needs more time without making something up?
While we're at it, has anyone ever seen a list of "action" words that are appropriate for psych documenting. My brain goes numb after too many "displays ...." or "denies..."
BTW, I HATE DOCUMENTATION. I know it's important but when I have to spend the last 2 hours of my day with pen and paper struggling to find something to say rather than spending time with patients I get a little cranky.
- 0Sep 24, '10 by GalRNI have my own issues with charting. After a few years traveling, mostly to places that used eMARs, I am back to paper charting. I've realized that electronic charting is good as far as time goes but doesn't really cover all the bases and often can be done by clicking enter, which leaves a bunch of notes stolen from the previous shift. But, it is quicker to type and the systems are less redundant.
On paper, I write and often look back at it and realize that I left out a detail or don't like the way I presented the info, but can't change it w/o rewriting the whole thing.
I just started a job at a place that uses BIRP notes and I hate them. We actually use PBIRP, with Problem being the first part. Thing is problem is really just the pt's Axis 1 diagnosis. So if the problem is Bipolar d/o, then I have to fit all of the behaviors relevent to that dx in the behavior part, and then address them all under interventions. There is no place for elaboration, so god forbid I have a conversation with a patient. There is really nowhere to chart the details.