Psych charting

  1. 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.?
    •  
  2. 24 Comments

  3. by   jkh
    You didn't say what your current format was. We use B.I.R.P. charting in our progress notes. Behavior. Intervention. Response. Plan. All displines (nsg, phyciatrist, dietary, social worker and therapies) use same notes and this seems to flow well and easy to track progress.
  4. by   crystalbrz
    We are currently using a narrative. The facility wanted a SOAP which is not feasible
    or practical in our line of nursing. Some DOCs feel the BIRP is too adolescent like for our adult units. We all agree with you. Hopefully we can do some convincing. Thank you for your reply.
  5. by   jimbob
    hey guys, sorry about ignorance but could someone please explain birp and soap for me? sounds more like personal hygiene and ADL's to me - here in nz we don't have any formal notation format but these may be helpful???
    tks
  6. by   jkh
    jimbob
    We use BIRP charting in our geropsychiatric unit. In a quick summary.
    B Behavior. The pts behavior including subjective and objective data, mood and affect.
    I Intervention. The nurses intervention to the behavior.
    R Response. The pts response to the intervention. Include progress of lack of tward care plan goals.
    P Plan. What is the plan to assist pt in progressing tward goals in the care plan.
    All disiplines use the same progress notes to track progress of lack of twards goals in the care plan. Each problem in the care plan has a number and you refer to that when doing your BIRP documentation.
    I hope this helps. I have never used SOAP so I can't explain that. This is just a quick overview and probally sounds confusing so if you have more questions let me know.
  7. by   smiley71
    dose anyone know were I can get sample B.I.R.P. notes?.....thank you
  8. by   DavidLCPCCSADC
    I'm used to SOAP and DAP but the current hospital I'm with is using APIE: A: Asssessment P: Problem,
    I: Interventions, E: Evaluation.
  9. by   aloevera
    we have no "acronyms" for our notes...we chart: mood, behavior, S/I, H/I,
    compliance with meds, reactions to any new meds, appetite, sleep, voiding, B/M's, and anything unusual or significant, anxiety level, depression level, pain level,
    ( I remember SOAP from nursing school but cannot remember what it is ?? )
  10. by   Whispera
    Subjective
    Objective
    Assessment
    Plan

    I surely hope you have some checklists or other easy ways to chart all that usual information!
  11. by   aloevera
    Quote from Whispera
    Subjective
    Objective
    Assessment
    Plan

    I surely hope you have some checklists or other easy ways to chart all that usual information!
    ahh, yes...it's been a looong time since school.....all of that falls under our charting forms....we don't really chart any "plans" on our psych unit....the tx. plan is assessed and charted on daily along with all of the above...
  12. by   SuperPsychdRN
    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.
  13. by   Ultra Violet
    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.
  14. by   Whispera
    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.

close