FIRST WEEK AT A NEW JOB AS A NEW PSYCH RN

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Specializes in medsurg to psych.

This is my first week training at a psych hospital. I am having a very hard time with my documentation. The hospital uses the PIR format and all of my charting is very redundant. Too redundant rather. Both my PIR charting and admissions/discharge documentations sound too much the same over and over. I would love to see some clever examples to keep me motivated and possibly to enhance my new-to-me field of nursing. I appreciate any and all suggestions as for I am in need of help!

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This is my first week as well  working in psych hospital. The charting is so different. I hope someone post some suggestions ?

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Specializes in Psych, Substance Abuse.

Use quotes in your documentation. Example:

Problem: Patient stated, "My anxiety is out of control. I feel like I can't focus."

Intervention: Psychiatrist notified. PRN hydroxyzine ordered and administered.

Response: Patient stated, "That helped. I feel better."

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