New to Nursing and Psych

psycorn · Dec 29, 2003

I think documentation is very important and in psy a lot of it is observation, it is important to d cument the patients behavior and effects of medication, or changes in vital signs or behavior in gerneral . Be careful do not diagnois ,just changes and observations, i think nurses are documenting to little,if there is no change then the note is very genreral, i amake it a habbit if i have to prn somebody i do a nsg note as to why, not just the prn note, this help the doctor change the medications to fit what i have described if i didn't document i would never interact with my docotrs due to working night shift and evening shift. there is no book, just remeber if its not documented it did not haappen, and when a chart goes tocourt years after an incident accurs you will not remember

PMHNP10 · Dec 30, 2003

I'm going to assume your facility has adopted the charting by exception, so do just that. Refer to what you learned in nursing school--clear and concise, present tense, no first person, etc. Early on I was told that if you have to do a takedown, do not write the details that any such activity was performed if no injury was incurred. Just say something like pt medicated with ativan 2mg IM and geodon 20mg IM for extreme agitation--maybe give a couple specifics if you feel they are pertinent. Putting down anything more about pt fighting and a takedown being required to subdue the pt would require you to chart the takedown as a restraint and therefore would require a ton more charting for a 30 second event.

Lindar · Mar 1, 2004

Well we are told on our unit to use what is called BIRP charting. B is behavoir. Chart what you see, their mood and affect and what are they doing. I is for Intervention-What did you do for this person meaning what is your nursing intervention. These interventions usually come from something we call a Treatment plan. They could be called care plans. R-response. How did the patient respond to the nursing intervention. They may or may not respond. Maybe you tried to distract or redirect and it was effective or ineffective. P-plan. What do you plan to do from here. This would be your goals. They too are usually in the Treatment Plan. It would look something like this.

B-Patient presented sitting in geri chair in day room, alert but oriented to person only. Grossly confused and combative. Fidgeting in chair and many attempts to ambulate. Patient uses walker to ambulate but gait is unsteady. Skin tear noted to left hand with steri strip intact. Patient is also hard of hearing. I-Attempted medication administration. Listened and attempted verbal redirection. Spoke in short concise concrete statements to accomodate hearing loss. R-Patient threw pills on the floor and stated, "I am not taking those unless God tells me to." P-Discuss with Physician possible secondary route for medication. Continue to monitor causes of patients agitation. Remove patient from stimulating situation. Continue to offer comfort and reassurance as needed.

I am probably not the best charter around but you get the idea. We actually chart the letters BIRP as I did above.

elkpark · Mar 2, 2004

I'm a state and Federal surveyor of inpatient psych units (and psych nurse of ~20 years), and feel the need to point out that what psychrn03 is recommending is a clear violation of Federal regulations (and probably your state regulations) regarding restraint, and could get the hospital and you, personally, in a lot of trouble. Not a flame -- just passing on information. I have seen it happen repeatedly. And, yes, we often figure it out even though you carefully neglected to chart it (not always, I'm sure, but often ...). What's wrong with just following the rules and doing it right in the first place? :)

FutureRNMichael · Mar 8, 2004

Excellent information in this thread. Very useful for a Psych CNA such as myself too.

Commander Vimes · Mar 8, 2004

Early on I was told that if you have to do a takedown, do not write the details that any such activity was performed if no injury was incurred.

:angryfire

I should hope that isnt the norm, if you have to perform Control and Restraint it should be documented fully, events leading upto, during and post event. An incident form also needs completing and signed by the manager. A doctor also needsto assess the patient to ensure he/she was not injured during the "takedown"

Ohh and can you change the wording takedown sounds like something out of the superbowl or Mike Tyson.

Most of all it should be last resort and documented as such. If you dont write it down how are we to know what it was for or wether there were any antecendents etc. And dont forget to update the Risk Assessment. :)

PMHNP10 · Mar 10, 2004

:angryfire
I should hope that isnt the norm, if you have to perform Control and Restraint it should be documented fully, events leading upto, during and post event. QUOTE]
I can't generalize as a matter of fact, but IMO the line of thinking I previously posted about is more prevalent than one might think. I'll never forget the incident. I had to give a pt a emergency IM. She was psychotic and was rapidly escalating, so wasn't willing to bend over and take the injection. I charted exactly what happened--that security had to physically take the pt. down onto the bed for the injection, etc.. My manager got wind of this incident and I received lecture upon lecture that I shouldn't have mentioned anything about having to take the pt down because then I'd have to do the booklet worth of restraint charting (which I do agree is rediculous). I was wondering why it wasn't enough to simply say what occurred and leave it at that without having to fill out another 6 pages of charting for a 15 second event (I'm not exaggerating). I was even asked to consider recharting to not include the physical restraint required--which I didn't do.
As for my OP I wasn't intending to say this is how it should be, but that is in fact how it reads. I think I was correct in charting the way I did, but unfortunately I was also wrong because I did not do the restraint paperwork. So I chalk it up to a learning experience.
Of course, the bottom line is that the med calmed the pt, and the pt got better.

CliveUK · Mar 10, 2004

I had to give a pt a emergency IM. She was psychotic and was rapidly escalating, so wasn't willing to bend over and take the injection. I charted exactly what happened--that security had to physically take the pt. down onto the bed for the injection, etc.. My manager got wind of this incident and I received lecture upon lecture that I shouldn't have mentioned anything about having to take the pt down because then I'd have to do the booklet worth of restraint charting (which I do agree is rediculous). I was wondering why it wasn't enough to simply say what occurred and leave it at that without having to fill out another 6 pages of charting for a 15 second event (I'm not exaggerating).

Your manager behaved incredibly badly in encouraging you NOT to document such an important event, just to save on paperwork! That just wouldn't be tolerated here in the UK. It may only have been a 15 second event, but there could have been all sorts of implications for the patient and for you. There have been cases of people who have died under restraint - what if that had occurred? I've known female patients who've claimed they've been raped when in fact they've been restrained. Without proper documentation, how can their account of events be refuted? Your manager needs a good talking-to by HIS/HER manager, if you ask me.

Commander Vimes · Mar 12, 2004

There appears to be a wide chasm between practice in the UK and our friends on the other side of the pond. We are recently in the aftremath of a public inquiry into the death of a young man named rocky bennett. He died whilst being restrained within a medium secure environment. Massive implications for the whole of mental health services within the uk.

Also within the UK we do not use "security personel" to restrain a patient, but nurses are trained in control and restraint techniques. I would feel uncomfortable having to ask a man in a uniform with no mental health training to restrain a patient. It would then appear to say that if you dont do what we want then ill call the security team! If a patient is extremely paranoid and delusional and beleives, as many do that the state is monitoring them and police are bugging them etc, then what does a security team coming in and holding them down so a nurse can inject a sedative say to the patient.

elkpark · Mar 12, 2004

I was wondering why it wasn't enough to simply say what occurred and leave it at that without having to fill out another 6 pages of charting for a 15 second event (I'm not exaggerating).

Because (once again), what you are describing is a flagrant violation of the Federal Conditions of Participation related to patient rights, which specificially define restraint and the rules that must be followed (and probably a violation of your state rules, also -- it certainly is a serious violation of the rules related to restraint & seclusion in my state). If it is discovered that a patient was restrained without all of the CMS requirements and rules being followed, you and the hospital can get into serious trouble. In a v. serious situation, the hospital could lose its certification to receive Medicare and Medicaid reimbursement (which pretty much shuts down most hospitals these days). It also frequently triggers a federal validation survey, in which an entire team of investigators comes in and goes over the entire hospital with a fine-toothed comb to look for possible violations of any other of the (many) CMS rules for acute care hospitals (your hospital really does not want to have a validation survey ...)

The hospital agreed to follow all the CMS rules as a condition of being certified for Medicare/Medicaid funding in the first place. I'm sure that hospital administration above your manager would not support what your manager is recommending. Sure, there's no guarantee that you'll get caught, but there's no guarantee that you won't -- I cite situations like this all the time, and the hospital gets in trouble with the state or the feds (and when the hospital administration is in trouble with the state or the feds, they are pretty put out with the individuals who put them into that situation). You are not "innocent until proven guilty," as was discussed on another recent thread on a similar topic -- if the investigators have reason to suspect that a restraint occurred, the burden is on the hospital to prove to us that it didn't, or that all the requirements to restrain someone were met. And, once we think we may have a situation in which that happened, we expand our sample and pull more charts, and look for more examples.

Besides, what's so awful about doing it the right way in the first place? Once you start "cutting corners" in your professional practice, where does it end? How many rules and laws, and which ones, that govern what you can and can't do on a psych unit is it ok to break? Most all of the rules that are in place now are there because of abuses of psych patients that occurred in the past. How many of their rights is it ok to ignore? You could also be opening yourself personally to civil or criminal charges (again, in a worst case scenario, but one never knows ...) Don't you expect healthcare providers who are treating you to follow all the rules, respect your legal/civil rights, and provide high quality care? I know that I certainly do! Aren't our patients entitled to the same? :)

lucianne · Mar 12, 2004

psychrn03, you're very lucky you didn't get caught. At our facility, if we have to call security they do their own reports about what they've done on the unit (and while they may not have mental health training, they are trained in safe physical management).

I don't think call security is a great solution, but we generally don't have enough staff to physically manage a patient and keep all the others safe even when we are at the upper limit of our staffing. Since I work in child and adolescent psych--and we only use security personnel for large adolescents or if we are at lower staffing levels--our restraints are rarely for psychotic individuals (our psychotic kids are usually, but not always, pretty peaceful). Sometimes for teens, the sight of the uniform is enough to help them get their behavior under control and accept a PRN med. Maybe it isn't the most therapeutic solution, but I think physical management even by psych staff is more traumatic to the patient.

We pretty much document every time we lay hands on someone. We strictly document all time outs longer than 15 minutes as restraints and get orders for them. All that paperwork is a deterrent to restraints--no one will do a restraint unless they absolutely have to and will be vigilant to try and head off escalating patients. It's also CYA. If you ever get called into court because someone claims they were injured during a restraint, you aren't likely to remember all the details--there are a few that stick out in my mind, but not many.

Back to the original poster: I think in psych it is better to overdocument than underdocument. What you're observing cannot be charted by exception. There's no need to do "he said--I said--then he did..." (like some of my coworkers do and then proceed to read the whole thing to me during report :rolleyes: ) but you can learn to succinctly summarize the situation. You'll learn the "catch phrases" to use and that will help.

luci