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Need help with charting...

Updated | Posted
by skyla1978 skyla1978 (New) New

Specializes in Psych!.

I started at a psych facility in September and, like many places probably are, there was no real training program in place.:uhoh3: So, I basically had to jump in and teach myself. The only thing I am struggling with after 3 months of work is charting. We use the PIR method (Prob, Intervention, Response). So, let me give you an example of my monotonous charting that I'm trying to change.

P: Potential for Self-Harm

I: RN 1:1 discussion about feelings. Monitor mood and interactions with others. Encourage group therapy participation.

R: Bright affect. Pt denies SI, HI, A/VH. Pt states she slept "well." Pt states she feels "good" today. Med-and meal-compliant. Social with select peers. No behavioral probs thus far.

I feel like I write the same darn thing for every single one of my 16 or so pts (unless a fight happens or a pt says something important). Is there anything else I can include or change about my R part?? Or my I part? I know my P part is right b/c we use the care plan to define the prob. I just want my charting to be more thorough and exciting and I don't want someone to read my charting and think, "She's useless! She just writes the same thing for every pt!" I am such a hard worker and I want that reflected in my charting, too! Please, please, please help! And I would so appreciate good examples. Most of my pts are suicidal (since they are adolescent females) and sometimes they are aggressive toward others.

Thank you in advance for anyone who helps me!!;)

Davey Do

Specializes in around 25 years psych, 15years medical. Has 42 years experience.

skyla1978:

It is an admirable trait you have, wanting to chart specifically, and not be redundant, on each and every patient.

Your basic format is fine. As you stated, you chart variances from the norm. If nothing SIGNIFICANT occurs, there's nothing else much to do, aside from some creative charting.

I've found that merely charting the patient's name (and not just "pt.") tends to make a note less generic. Quotes are always good. Addressing circumstances specific to the Individual is another tact in avoiding repetitious redundancy.

For example:

P: Potential for self harm. Precipatating reason for admission is John Doe threatened to walk out into traffic.

I: John and I discussed his reasons for his plan of self-harm. He said, "I hadn't been taking my Celexa for about two weeks. I went out and got drunk... I began thinking how crappy my life was. So I wanted to end it." We discussed the importance of treatment compliance: taking medication even if he wasn't feeling bad, abstaining from alcohol as much as possible, and keeping appointments with his Therapist and Doctor. John has been med compliant as an inpatient, has actively attended groups, and presently denies feeling suicidal. I reinforced his decision to contact EMS before he did something he would have later regretted.

R: John said that he appreciated my support. He also said that he plans to address the specific issues that made him feel "crappy" with his Therapist. John also noted that he realized how important it is to keep his Doctor informed of his status.

This has been a generic scenerio, based on your format, that I like to use.

If it is condusive to your needs, feel free to PM me PRN. I would discussing enjoy creative charting with you. Either way, the best to you, skyla1978.

Dave

Edited by Davey Do

skyla1978

Specializes in Psych!.

davey do said:
skyla1978:

It is an admirable trait you have, wanting to chart specifically, and not be redundant, on each and every patient.

Your basic format is fine. As you stated, you chart variances from the norm. If nothing significant occurs, there's nothing else much to do, aside from some creative charting.

I've found that merely charting the patient's name (and not just "pt.") tends to make a note less generic. Quotes are always good. Addressing circumstances specific to the individual is another tact in avoiding repetitious redundancy.

For example:

P: Potential for self harm. Precipatating reason for admission is john doe threatened to walk out into traffic.

I: John and I discussed his reasons for his plan of self-harm. He said, "I hadn't been taking my celexa for about two weeks. I went out and got drunk... I began thinking how crappy my life was. So I wanted to end it." we discussed the importance of treatment compliance: Taking medication even if he wasn't feeling bad, abstaining from alcohol as much as possible, and keeping appointments with his therapist and doctor. John has been med compliant as an inpatient, has actively attended groups, and presently denies feeling suicidal. I reinforced his decision to contact ems before he did something he would have later regretted.

R: John said that he appreciated my support. He also said that he plans to address the specific issues that made him feel "crappy" with his therapist. John also noted that he realized how important it is to keep his doctor informed of his status.

This has been a generic scenerio, based on your format, that I like to use.

If it is condusive to your needs, feel free to pm me prn. I would discussing enjoy creative charting with you. Either way, the best to you, skyla1978.

Dave

thank you sooooo much, dave!!!

MentalRN74

Specializes in Psych- child, adolescent, adult, and CD. Has 13 years experience.

I often add something about:

-whether they make eye contact

-what their appearance is like (neat or disheveled)

-that even though they deny any hallucinations they seem to be responding to internal stimuli AEB talking to and laughing at unseen individuals

-whether or not they exhibit insight into the reason for admission or their pre-admit behaviors

-that encouragement was given to be or become more active in the milieu

-somatic with numerous physical complaints (which many adolescent females are- for years I worked with adol)

-admits to having thoughts of harming self, no plan, and agrees to come to staff if she begins to feel like acting on the feelings

-made vague verbal threats to peers or staff

But Davey was correct, your format is good. We use BIRP, so that's what I'm used to seeing. I'm like you, sometimes I get a group of patients (I work with adults now.) that just sit in their rooms and don't *do* anything or really even say anything. It makes it hard to chart anything but the basics on them.

Good luck with your psych nursing career, and welcome aboard!

Popwhizbangz, LPN

Specializes in psych, geriatrics. Has 10 years experience.

Where I work we have a form with check boxes allowing for a comprehensive documentation daily, head to toe, ADLs, interactions, mental status, Rx adherence, you name it, all on one page, with much less work than you'd think because you can check a box for groups of normal findings, and add a word here and there to add more detail. On the back we have an unstructured narrative note - more detail, sometimes a lot, sometimes very little, all up to individual judgement and time constraints, and we use the back to indicate changes (if any) later in the day from the information on the front done on the day shift. It makes life much easier and helps keep the insurance companies and regulators happy.

Our standard requires a nurses note once a day minimum (Night shift not included) and as needed otherwise clinically. Aides do notes too, making the whole thing much more manageable for RNs.

I could scan and email a copy if anyone's interested.:D

Popwhizbangz, LPN

Specializes in psych, geriatrics. Has 10 years experience.

:D I can also provide various brief guides to psych nursing documentation and assessment - key areas and vocabulary, SIGECAPS for depression, DIGFAST for mania, pertinent negatives and positives, etc. With a little practice you can produce much more useful & impressive output very efficiently I.e. with less work :D:up:

Simply Complicated

Specializes in Med/Surg, Neuro, ICU, travel RN, Psych. Has 5 years experience.

Popwhizbang, I would love if you provided those guides! Don't mean to hijack OP's thread. I am still learning all this as well, as I've only been doing it a couple months.

Popwhizbangz, LPN

Specializes in psych, geriatrics. Has 10 years experience.

OK, update time. I've made some progress gathering dome documention Helpers in a format I can e- forward. Should be able to post specific offerings Monday or so, I'll keep you all posted. I work at a hospital with extensive training resources built up over years, and I would be more than happy to spread the wealth - post me if interested, as some already have.

Edited by Popwhizbangz

Hello there, I just started in a hospital designed for the geriatric psych pop and I would appreciate anything you are willing to share/pass along. Don't know how to PM as I'm using a mobile device but my email is on my profile.

NYRN08

Specializes in Pysch, Corrections, MedSurg.

I would be interested in gettin the documentation. I too, am new to psych. I only have a year under my belt (but in corrections) and only 6 mths in mental health and bio-chemical dependency. I have alot to learn and would love to see what you have. I could always learn to do better charting. At my facility we do SOAP notes in the day and narrative notes at night. I do way better with my narrative note than I do with my SOAP note. I feel like I am writing the samething over and over and over....lol

Popwhizbangz, LPN

Specializes in psych, geriatrics. Has 10 years experience.

Documentation Help Update -

Been experimenting with providing URL links - doing individual emails is a bit clumsy & slow on this site (limit one every 60sec & hard for my brain to keep track of them all), PLEASE anyone left out don't take it personally, it's just the limits of my poor tired brain.

Perhaps here's an easier way: I'll post links for all. Here's one, hope it opens OK, its the Documentation Manual from McLean Hospital, an all-psych approx 150 bed Harvard teaching hospital with lots of educational resources (and a good place to work by the way, esp. if you want to learn, teach, or do research). I teach and work there.

Anyway, try this link:

http://mclean.partners.org/departments/nursing/documentationManual.aspx

Please let me know how/if it works, so I can tweak it if need be.

More will follow, if and when I'm not working, sleeping, or shoveling snow..... - Pop :yeah:

Popwhizbangz, LPN

Specializes in psych, geriatrics. Has 10 years experience.

Here's a cut & paste from a sheet I wrote up for students and patients.

Its the DIGFAST mnemonic for Manic symptoms:

"D - Distractable

I - Inflated and/or Impaired

G - Grandiose

F - Flight of Ideas, Racing Thoughts

A - Activity: Increased and more Risky

S - Sleep: diminished amount and/or need

T - Talkative, Pressured

In general, Mania consists of a distinct period of abnormally and persistently elevated, expansive, and/or irritable mood.

Psychosis may arise, e.g. paranoia, delusions, etc.

If symptoms do not (yet) cause marked impairment in occupational and/or social functioning, the term used is Hypomania."

Hope its useful. Feel free to copy - Pop :yeah: