Psych charting

[crystalbrz]

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.?

[GalRN]

I 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.