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.
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.