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Discussion

Need help with charting...

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!!;)

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    I am returning to psych nursing after 15 years as a pediatric RN. I would really appreciate a copy of your nursing note form since it seems so comprehensive. The facility I work for could benefit from some positive changes that allow for thorough documentation.

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    Good Afternoon. Can you please send me some of the psych nursing documentation you mentioned above please. I currently work at a psych facility with both adults and adolescents and we do SOAP charting. I want my charting to be as detailed as the nurses who have worked here for some years. I strive daily to learn everything I can to be a team player and to carry my own weight equally as my team. I need to expand my vocabulary and interpretation of what I observe while on the floor. My email address is [email protected]. I would truly appreciate it. thank you in advance. I'll check back here in case info can be sent this way. Again I would truly appreciate it. I realize this posting is from 2011, I hope this email finds you well.

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    I would be very interested in seeing this! I've been trying to develop a tick-charting system for our unit. Would you be able to email me a copy? [email protected]

    Thanks!

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    I've actually just started a new thread on this very topic. I would love any and all help with this as well. [email protected]

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    Good evening, I just start as a psych nurse, I'm so nervous on charting, can someone send me the chart sample, thank you, [email protected]

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    Popwhizbangz said:

    OK, another update:

    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....

    Hi! can I ask for a copy as well... [email protected] 

    Thank you!

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