I started at a psych facility in September and, like many places probably are, there was no real training program in place. 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.
1) Please understand my dismay & embarrassment for moving so slow on providing what I thought would be very simple & easy to provide (one page!!!!! with very little text arggg)
2) I'm still working on it, got the old HP scanner & my Mac on speaking terms (I think... HP software doesn't play well with others in my humble experience) so hopefully Ican post a psych progress note form very soon. It becomes increasingly clear why I'm not in IT....
I finally managed to scan & attach that pesky documentation form for psych staff. The main point is, if you want to save time/effort and/or improve your documentation, pre-made forms are the way to go - small upfront investment, then years of much improved efficiency. The attached form is just an example, has been in use for many years, by thousands of writers - very useful.
Hopefully its useable and/or helpful somehow, let me know....
I appreciate the trouble you have gone to...I was able to use the link you provided on all nurses..I will also email you back with my regular email just in case you have any other tidbits of info to share...Thanks:yeah:
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.
Popwhizbangz, LPN
115 Posts
Another useful mnemonic is SIGECAPS, for symptoms often found with Depression:
S: Suicidality. Assess/document SI, intent, plan (Viable? Immediate?), impulsivity, contracting for safety
I: Interest
G: Guilt
E: Energy
C: Concentration
A: Appetite
P: Psychomotor Retardation
S: Sleep, Sex
I often document, when pressed for time, with SIGECAPS with arrows up, down, etc. - LOTS of information communicated very efficiently - Pop