I'm a LPN working in a Cris Stabilization Unit of a Psychiatric Hospital. The clients are primarily low/no income street people who rotate in and out usually due to non-complaince with medications.
Heres my question, what should I chart? As the LPN I primarily handle the med pass, transcribe doc orders, and give ETO's (aka the booty shot).
My charting consists of part med compliance and then a note about sleeping (work overnights). I think I'm missing something.
Are there any data points that should be noted with every entry?
Thanks in advance