New Grad Psych Charting Difficulties=(

[PsychRN05]

Help! I'm a new grad working in a Geriatric Psychiatry Unit and I'm really worried about my documentation. We use the BIRP method of charting and I never know what to write for my interventions or the plan part. I'm having difficulty recognizing what interventions I perfomed. In nursing school, our psych rotation was very brief and we never even charted during our psych clinicals. Med-Surg interventions have always been obvious to me, you know- changed a dressing, yada yada.. But psych.. I never know what to write!! The basics are always there, but I feel like I leave out so much and that there's other things I did. Is it appropriate to put a therapeutic communication technique as an intervention? I spend so much time with my patients and I want my charting to reflect that, but I really dont how to put into words my interventions. Anyone have any charting phrases that may help out? I'd appreciate VERY much!!!!! Thanks=)

[Thunderwolf, MSN, RN]

You may want to invest or pick up a Psych Nursing Care Plan book which lists commonly seen behaviors/illnesses with cooresponding nursing interventions. This may be a starting point for you.

Wolfie

[spaniel]

As much as I dislike using "buzz-words", they can help with charting. Some interventions can be listed as : cognitive restructuring, validation of emotions, creative refocusing, active problem solving, engaged in relaxation exercise, etc etc.

[CharlieRN]

Practical suggestion: read your collegues notes and let them be your guide. If one of them uses a phrase you don't understand in the contex you can ask the person about what exactly they ment. This has the advantage of helping to make you "speak the same language" as your peers. Each institution has its own shorthand of expressions to discribe the theraputic process.

I agree about avoiding buzz words. But our interventions are going to sound vague anyway. "listened to patient" may have been the essence of it, but it does no harm to try to make that sound a bit more professional.