Charting on psych patients

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Need help charting on psych patients. Basically I know what to chart about I just need help with the terminology. Can someone give me examples of terms or phrases used to describe different moods, thoughts and behaviors? I have looked something's up and it just gives me a vague definition. Help! New psych nurse here

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Specializes in Psych.

Which ones are you not sure about?

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Specializes in Psychiatry, Mental Health.
Which ones are you not sure about?

In addition, you can describe a situation or an observation and tell us how you think it should be charted. Your question is far too vague for us to help you.

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Specializes in Psych ICU, addictions.

Here's some AN threads that may help you:

https://allnurses.com/psychiatric-nursing/psych-charting-255388.html

https://allnurses.com/psychiatric-nursing/i-seriously-need-370599.html

https://allnurses.com/psychiatric-nursing/need-help-charting-520221.html

And I agree with the other posters: if you can give us the specific terms/phrases/situations you are not sure about, we can elaborate.

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Specializes in Outpatient Psychiatry.

I have a phone app with a psychiatric dictionary of sorts in it. It's not a professional app, but it helps with words "normal nurses" (lol) don't always use like akathisia, coprolalia, word-salad, and such. I'm not sure if this is the kind of help you're looking for. Oh, and the app, Psychiatry Dictionary, is in the Google Play Store.

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Specializes in Psych Nurse.

This is exactly what I am struggling with right now. More experienced nurses use psych terms effectively. 

like labile, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, self-contemptuous, frightened, and perplexed.

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Specializes in Emergency Medicine/Trauma/Psych/Private Duty/Peds.

Not sure exactly what you are asking for?...

Are you asking for the terms themselves or an explanation of the terms?

If you are looking for an explanation I would reference your physical assessment book as this would give a full description for such terms.

If it helps with documentation....for each pt I always list the below:

Document current activity: ie-sleeping, sitting on edge of bed, interacting with peers or activities, posturing

Affect: labile, flat, restricted, blunted, full range

Mood: sad, happy, excited, manic, elated, angry, enraged, hopeless, grandiose

Speech: pressured, flow, rapid, organized, disorganized, incoherent, mumbled

Thought process/content: disorganized, tangential, loose assoc, delusional, organized

Dress: disheveled, clean, neat, appropriate

Food: consumed

Sleep: # hrs.

Suicidal: y/n with plan or without

AV hallucinations with or without command

 

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