The big problem with psych is that many nurses, even ones that have been around for a bit, tend to only chart on psych issues and forget to include crucial medical information. If you are charting for medicare/medicaid and some private insurance companies you need to include the following data.
Orientation, Pain, appetite and sleep. Ability to ambulate and ADL's. You should include if the patient has s&s of contagious disease and with Covid we need to include that we educated the patient about covid and if he/she understood the teaching. Now for the psyc part which can be any thing of a psych nature that you observe or is reported to you by floor staff.
Here's an example.
Patient (Name) is awake, alert, oriented times 3 and medically stable. Vital signs are within normal limits for (name) baseline. HE is able to ambulate and perform ADLs independantly. There is no C/O pain, elevation in temperature or respiriatory illness noted. (Name) was educated regarding Corona Virus/Covid 19 and the importance of handwashing, covering the face and nose and maintaining a six foot social distance to prevent disease transmission.(Name) was receptive to teaching. (Name) is currently on 5150 DTS/DTO after having made threats to "shoot up" the neighborhood and brandishing a shotgun when police arrived. (Name) states he has been seeing giant cats in the neighborhood and they want to eat him. This writer inquired if (Name) feels safe in the hospital. (Name agreed) he felt safe at this time. He is attending groups and program activities without prompting but tends to keep to himself during free time. This writer encouraged him to stay compliant with medications and treatment, to seek out staff if thoughts to harm self or others or if thoughts about the cats become overwhelming. Will continue to monitor safety every 15 minutes and provide a supportive environment.
Remember that many insurance companies will deny payment unless the patient is suicidal/homicidal or gravely disabled by reason of mental illness.
Hope this helps
Hppy
