Published
I don't know of any actual resource for this...I always made my own....though I'm in psych ER now so I don't use them anymore. The set up is different but I did use one everyday on inpatient. I, unfortunately, don't have it on my computer any longer as it's been a long time. I always found I was pretty OCD about having my sheets my way....with the info I needed....I am happy to help if you don't find anyone with one they can e-mail ya or something....if you are not computer savey with that kind thing.
I am a new nurse in a short term acute MH facility which is part of a large hospital. The following is how I give report:
Pt name / Room # / Dx / why and how pt came to facility
Report any SI, HI, Auditory/Visual Hallucinations. If positive SI or HI - do they have a plan? Any past attempts?
Pt behavior and my assessment including pain
How pt is responding to milieu and any safety issues
Med compliance and what PRN meds are ordered and what pt has used during my shift and the results
Any pertinent orders that need to be addressed or followed up on as well as pt goals that need to be monitored
I keep my report as brief and to the point as I can possible.
Hope this helps;)
ddds
3 Posts
Hi, looking for some help. Would like access to templates used for inpatient psych report sheets. Our unit uses a taped report for shift change. Looking for some ideas to make the report sheet more concise and workable. Can you help?