Mental Health Daily Nursing Notes

[DestinyS29]

I recently began working at a small residential care facility with residents that have either mental health diagnoses, intellectual disability or a combination of both. I used to work in an ICU an then an Emergency room, in both places we had electronic records in which I had to complete an assessment (ICU, head to toe and ER focused) with minimal notes for those things that weren't charted in the assessment. Now I'm working at a facility that has no software for charting assessments, and the nurse who used to work here just occasionally hand wrote notes when something out of the norm occurred. Behaviors are charted separately by all staff members, not just the nurse or CMA on duty. I would feel more comfortable typing up a daily nursing assessment/progress note on all of the residents rather than just putting a note in when something out of the norm occurs, especially as I feel it needs to be done at least daily if not each shift by the med staff. (Charting is done on all shifts by program assistants regarding their safety, whereabouts, ADL's and activities so it's not like they aren't being charted on daily). My problem is that I'm not sure the best things to put in my notes for daily assessment or progress. Most residents only have vital signs taken every week or only once a month, most of them do not present with any complaints on a daily basis. I obviously do a quick assessment of them each morning during med pass and chart any complaints or concerns but I would greatly appreciate advice on a daily template or other suggestions of what to put in the daily notes. This is so different than what I'm used to, please help!

Any advice is much appreciated!

[DUDERNGUY, BSN, MSN]

sounds like you are coming from a well controlled icu setting to a cost cutting/LTC setting. it is very different. It would not hurt IMO if you wrote a 30second note in each patients chart that said something like "no complaints from patient, no change from baseline status, safety maintained, blah blah blah" so that at least you have something basic to cover your ass if you had to. But do not spend to much time on that, in this setting if nothing happened nothing is charted i guess.

[DestinyS29]

That's kind of what I'm wanting to do, just something simple so at least if I ever needed it I could show documentation on their current mental/physical health so it doesn't look like I'm neglecting their needs. They hand write every thing here but I've made a template in excel so that I can save time by typing and will just print them out when I have a full page of notes. I'm just trying to get a feel for what others would be charting on. I usually chart orientation, no complaints (unless they have them) and will continue to monitor. I have seen some others warnings about charting "will continue to monitor" or things about safety only because if something happens to them they could say, you said you would provide safety, where were you? And obviously there is only one of me and 30 residents so I can't be everywhere all the time. Just want to make sure I'm including enough. (Which anything would probably be enough since nothing was being done daily before...)

[DUDERNGUY, BSN, MSN]

That's kind of what I'm wanting to do, just something simple so at least if I ever needed it I could show documentation on their current mental/physical health so it doesn't look like I'm neglecting their needs. They hand write every thing here but I've made a template in excel so that I can save time by typing and will just print them out when I have a full page of notes. I'm just trying to get a feel for what others would be charting on. I usually chart orientation, no complaints (unless they have them) and will continue to monitor. I have seen some others warnings about charting "will continue to monitor" or things about safety only because if something happens to them they could say, you said you would provide safety, where were you? And obviously there is only one of me and 30 residents so I can't be everywhere all the time. Just want to make sure I'm including enough. (Which anything would probably be enough since nothing was being done daily before...)

i understand your point that those vague statments can be argued as more trouble then good. I guess it really boils down to what is the units policy? I know when i worked LTC it was notes once weekly and as needed on patients. And when i worked rehab/sub acute it was once daily (days did odd numbers and nights did even number rooms) and as needed. Acute care i did a note on everyone. Find out from management. But as long as you are charting on important events, if any, i do not see much of an issue. Again you are coming from the ICU. Quite the jump. That is like a LTC nurse going straight into ICU, quite the opposite spectrum.