I seriously need HELP in Psych Documentation!

Whispera, MSN, RN · Feb 16, 2009

affect, mood, suicidal ideation (active or passive) and what you did about it, evidence of hallucinations, delusions, paranoia

monitored Q30 minutes

interaction with others, participation in groups (active or passive)

prns requested or needed and their effects

wellseasoned · Feb 16, 2009

:idea:Is there no education/orientation for you formally at your workplace? If not, perhaps you could ask who is considered tops with documentation and have some informal mentoring. I learned alot in my clinical rotation and by having spent years as a nurses aide reading case studies. Maybe you could buy a textbook, or get some more info on line. We don't know what we haven't been taught- please continue to ask for help. :down:

Mr Ian · Feb 16, 2009

To add to whispera's list - behaviour and content of conversations. Energy levels, sleep, any s/e's evident, interpersonal relations - isolating/mixing; ability to engage in conversation; concentrate on activities; problem solve - and all manner of functional living skills and activities.

The 'odd' things are always worth noting and often the not-odd things that used to be there (eg; "not observed to be responding to unseen/unherd stimuli"; not spending all day sat in the corner of the garden; not drinking coke all day).

A tip would be to check the care plan and correspond your clinical entry to that (if they have one worth commenting on).

Whispera, MSN, RN · Feb 16, 2009

As Ian said, check the care plan. Some places require that charting reflects what's on the care plan....so, for instance...the care plan says the patient will remain free from self-harm. You chart that the patient remained safe on Q15 minute checks and that you will continue to monitor for safety... something like that... (I like ...'s)

RochesterRN-BSN, BSN, RN · Feb 16, 2009

Sounds like you need more then what we can tell you here---starting from scratch in psych in outpatient is not common around where I am--generally people work inpatient first.......I would highly suggest getting a book specifically on psych assessment and documentation....there are a few good ones out there if you look them up on-line aon barnes and noble or something.That is my suggestion so that you get the training you need to feel comfortable,,,,,they really should have had an orientation with this info. My first psych nursing job we had a pysh CNS that did like a 3 or 4 day review of all the basics in psych nurisng, safety, documentation, etc. It was helpful to me. But if you have to do this on your own I would say get a book.

RochesterRN-BSN, BSN, RN · Feb 16, 2009

Try getting a book like this to read and have as a reference until all of this comes more naturally---

http://www.fadavis.com/online_store/catalog/catalog_detail.cfm?publication_id=2410

TsavarenaRN · Feb 21, 2009

Sorry this is a little long, but I had an awesome psych instructor in nursing school that taught me this train of thought for mental health assessment. Also inservice at work was slightly helpful. This is based on an entire written narrative, mine at the facility I work at has a quick-look checklist on the front of the assessment that covers the majority of assessment with writing area on the back to cover problems/interventions and anything not covered in the checklist.

I always think of Maslow's when I chart, and just expand on the area concerning the reason the patient is in the hospital and not in outpatient treatment. http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs (quick refresher) Focus on any problems that you verify, how you intervened, and what was the outcome? Like the above poster said, chart the abnormal, out of range, problems voiced by patient. But keep the questions listed below in your head as you assess. This covers your behind, and keeps their insurance covering them (particularly Medicare/Medicaid, I notice their chart people checking up on the nursing assessments pretty regularly).

I address the Pysiological briefly first because if they aren't breathing or have horrible chest pain, their shizo or depression becomes a very secondary concern. Assess: Are they in any pain? Any fresh looking wounds or bruises? Vital signs normal? Are they losing/gaining weight? Notice any signs of Tardive Dyskinesia or Extra Pyramidal neuro symptoms from the pysch meds? Have they been eating? Sleeping? Usually if nothing is present this can be covered with a simple 'NAD' (no acute distress) if your facility allows this abbreviation. If there's a complaint, chart what they stated, signs and symptoms and how you intervened.

Next I address the Safety, thinking of: Are they having any financial problems? Have they been allowed to speak with their family/close friends? How was that experience? Homesick? Worried about their children on the outside? Their job? How do they feel about where they are going when they leave the facility? (Mine are acute 90 day, so this may not always apply.) How have the staff been treating them? Are they having audio/visual hallucinations? Nightmares? Did they tell you they are contemplating suicide or homicidal intentions? If so, chart how you intervened (Counseled pt 1:1, called to alert Doc for orders/PRNs, asked what more we can be doing for their tx and what their response was, place on suicide/assault watch, placed on visual contact, etc.) How do they feel their medications are working for them and did they have any concerns?

Love and Belonging and Esteem sorta go together, for these: Are they dressed apropriately? Are ADLs completed? How are they getting along with their peers? Are they participating in group? Are they interacting apropriately with staff and peers (being respectful/disrespectful, withdrawn, isolating)? Are they saying things to indicate they I have self esteem issues? "I hate myself and everyone else." "I'm hopeless." "These groups are useless." Are they depressed or anxious? Will they admit to being depressed or anxious? Have them rate these on a 1-10 scale. Do they have fears of returning to their family or job after being placed in a mental facility? (Again this may not apply to long-term or life-long commitment) They can pretty much ignore or avoid these questions at which point I would chart "guarded, will attempt to approach pt. again" and follow up with that later.

Self Actualization ties in with the above if they can even admit to why they have been involuntarily placed in the facility. "Patient denies any depression/audio visual hallucinations/suicidal homicidal ideations." "Denies paronoid thoughts." Do they feel motivated for tx? Do they feel an improvement with their problem? This also addresses their insight, which can be poor or good depending on how well they understand their situation. Which should also be charted.

From this point I wrap it up with how good was their eye contact? Was their speech normal, clear, rapid, coherent? How was their mood? Calm, somatic, manipulative, anxious, depressed, labile, hyperactive, manic? Affect? Flat, blunted, WNL (within normal limits), irritable, guarded, euthymic, elevated?

Chart that you asked them if they have any other requests or conerns, what they stated, and how you intervened or addressed it. I always also chart that I encouraged them to come to staff if they begin to feel out of control or have suicidal/homicidal intentions, or pain; and if they verbalized or "nodded" understanding, or if they appeared to ignore me.

Even if they deny a/v hallucinations, did it seem they may have been responding to internal stimuli? Did you notice their answers delayed or did they keep looking away from you off to the side?

I tend to chart a lot of "patient stated ........" or "pt verbalized......." as mental health isn't something you can monitor with labwork and machines, but by their behavior and the things they say.

I see this constantly but I would advise to NEVER EVER chart this: "Will continue to monitor and provide safe theraputic environment." I was told by legal counsel that writing this puts you under even more scrutiny if something uncontrollable happens such as: fight breaks out between pts while they are off unit in cafe or outside and injuries were sustained before they could be stopped, one of them slips and falls, breaking a leg, while they are with the mental health techs. A pt. codes and dies. Didn't YOU just chart that YOU were monitoring them and providing the safe theraputic environment? Where were YOU? Of course if things like this happen it still falls under your liscense and liability but by charting the above you are saying that you are right there with the pts. all the time, and I know I am incapable of doing this at my facility. So where were YOU when the incident happened? Legally this statement will press even more liability onto you and can be used as another tool against you in court. This also applies to med/surg. (Getting off my soapbox now :bugeyes: )

This seems super long, but my actual narrative is anywhere from about 5-10 lines just depending on if the patient has had any changes or is acting bizarre. Checklists save tons of time, as does learning and using your facility's approved abbreviations. The more of them you do, the faster you will become at them. Hope this helps! :heartbeat

Whispera, MSN, RN · Feb 21, 2009

In agreeing with the above poster, I want to say, never ever ever say something will be done that you can't guarantee someone will do. For instance, if you're going off-duty and the next shift is coming on, and you're writing your last note, don't say "will encourage pt to participate in groups."