Mental health documentation

[sykepleierstudent]

Hi,

I am an LPN student and had a few hours rotation/observation on a Mental Health Unit.Now I have an assignment to do.I have to describe the difference in documentation between Med-Surg and mental health charting.Unfortunately I did not have a chance to look in any of the charts.Can anyone please help me?

Thank you so much!

[phoenixfire]

I'm in an ADN program at my local junior college, and in our psych rotation, the biggest difference I noted in charting is the type of information that is noted. For example, with a psych patient, you have to pay attention to how they look (affect, mood, etc) how they sound (high voice, low, tone, amount of words, etc) and you have to be able to correctly identify types of speech (neoligisms, word salad, loose associations, etc). The psych charting is much more about how the person is acting overall, especially with quotations of what the patient has said to the nurse. Look at some psych care plans, and see if maybe you can't get a better idea.

I'm not sure how in depth your intructor is looking for you to be in your assignment, but I would always rather have too much information than not enough. Hope this helps!

[sykepleierstudent]

phoenixfire,

Thank you so much for your answer!!That is what I though,but I was not sure.Good luck to you and your studies!

[GingerSue]

here's a link to some psych care plans:

http://www.fadavis.com/townsend4e/additionalnursingcareplans.asp