Act Nurse question about progress notes/documentation

Sugare82 · Feb 18, 2018

I have worked for two different ACT teams. Basically where I am now uses PIE charting. Where I was before used SOAP notes. Both of these software programs were targeted for social work realms, so nursing documentation is all narrative. No more check lists to guide you. Definitely document any physical nursing assessments done, ie CBG or blood pressure, as this will help the team meet fidelity and medicaid requirements. In addition, of course always document completely any injection given with name, dose and frequency of injection and the injection site. Psychiatric interventions are less concrete, so this is where the learning curve comes in. It is important to learn the assessment and intervention language associated with mental health interventions, i.e. describing affect, thought processes, mood and behavior. Then stating clearly what was done in response, i.e. reinforced coping skills teaching, listened empathetically or provided health/medication education. Pay attention to the culture in which you work and perhaps spend some time previous notes on clients you are familiar with to get a better idea of the expectations. I love being an ACTT RN, but it is not for everyone. You will know soon enough if you fit.

Good Luck-The fact you are asking shows you care, and that is the biggest step.

CP1983, BSN, RN, APRN, NP · Feb 20, 2018

Thanks Sugare82! I was actually looking at previous progress notes from our patients to get an idea but what you mentioned in your posting is exactly what's described as our format.

We do have a template that we use so that helps us in terms of staying on track.

Yes, I definitely want to do things correctly because like you said, we have to meet requirements and our visits are billable so staying compliant with governmental regulations are important. Thanks for responding, :-)