Aside from assessing their mood, suicidal ideation, hallucinations etc which all help to determine if medication is being effective and a generalized medical including vitals etc. Take the time to learn exactly what led to them ending up there with you. Off meds? Why? You may can help with resources to fix that issue while you encourage them not to wait so long before doing something about it so as not to see you again. Most psych patients are repeats and instantly feel better when coming in because you are there and already know a lot about their mental health hx, family, living conditions, coping skills, substance abuse etc. So in a way it’s like ongoing therapy. A chance to reassess if the patient is implementing the skills taught while in your facility before. You have the opportunity to reenforce teachings and find out if they are still working on same goals or making new ones. Need assistance on HOW to accomplish a goal. And on a personal level how is the loved one diagnosed with an illness before last admission? How’s the daughter they got to see? Whatever information you got from them before? Most of all you are building a Report based on trust. And you saved their life more times than you know because you care & in the darkest moments they remember what you said, did, gave them to read to help so instead of harming themselves or others they returned to you.
P.S Be careful about the way you ask when a patient is ready to discharge. Few are really ever ready. I had a patient that had eaten jagged tin in a state hospital with cameras & staff all around. I wondered why, and also wanted to make sure he didn’t try anything similar in my facility so I ask him, why? What made you do that at that moment? ANSWER: Because, all they kept asking me was “When do you think you will be ready to go home? What is it we need to work on to get you back home? What else do you need to be ready for d/c? “ Not once did they ask me how I was really feeling other than how my meds were affecting me. Not once did one staff member talk to me without mentioning “When I was going to be leaving “. ... Home if there is one isn’t always such a good place to go back to. Back to what triggered them in the 1st place. Back to emotional, physical or sexual abuse. Multiple people in the home & no room of their own, drug and alcohol use which it’s hard to say no to your mama or abusive father that’s supplying it. Or looking at the person That assaulted you no one else knows about because you can’t bring yourself to tell. No home isn’t what most patients are looking forward to. Somehow you have to give them the encouragement & compliment each tiny improvement you recognize each day so that they believe they have the strength to go back home...until another day comes..