Writing progress Notes in Psyc

We always chart in accordance to the Treatment plan problems....and of course, there are guidelines on the notes to answer to
If there are any statments made by the pt. that the Dr. should be aware of, or anything you deem important, any medical problems that need to be addressed, etc. You can never write too much on a progress note !!

Mood, affect, facial expressions, body language, posture, what the patient says, how they say it. Their behaviors. etc....

Be sure to address any sucidial or homicidal ideations as well.

I try to address the following in my notes:

• SI/HI
• AH/VH
• safety
• anxiety
• need for PRN medications
• affect
• behavior
• group attendance

Your facility might have a specific format it uses for notes. Some use SOAP (subjective, objective, assessment, plan)charting. Some use DIRP (data, interventions, response, plan). Ask around and look at the charts to see what's there. I had worked several months before anyone told me that I should be using a specific format, and then I did notice it in others' charting. It's one of those things that sometimes doesn't get covered enough in orientation.