psych charting

Thunderwolf, MSN, RN · Oct 14, 2007

The charting statement that you provide is general....which means just general encouragement is provided. If you are looking for something more specific to write....what specifically are you requesting the patient to do?....then, chart that specific chart statement. That may help.

dan_aus · Oct 16, 2007

hi there,

the best way of charting i have found is to do a mental state.

a general guide line that i would use for this would be:

appeareance: clothing, hygiene etc. you only need to comment on things of relevance. ie: clients experiencing mania could be wearing clothes inappropriate to the weather, alot of make-up etc.

behaviour: how is the client interacting with others? psycho-motor agitation? intrusive? limit setting required? etc.

mood: how does the client explain how they are feeling

affect: objective description of clients mood

speech: pressured? loud?

thought form: flight of ideas? tangential? circumstantial? blocking? basically any abnormalities in thought processes.

Thought content: delusional ideation? sucidial/self-harm ideation- included here you should discuss intention, discuss the means of suicide, action taken etc.

percetion: discuss hallucinations i.e: auditory hallucinations- discuss what the voices are saying- distressing for the client? intenstity, frequency, is there anything that helps the client be distracted.

insight/judgement

and you know what, i have drawn a blank.... but thats the basic way i would document.

hope this helps and please ask me any questions...

PsychNurseWannaBe, BSN, RN · Oct 22, 2007

We chart using SOIAPE; subjective, objective, impression, action, plan and education. If done right every level addresses or supports the subjective and it flows quite nicely. The impression area is where I chart nursing dx, which will help in the action, plan and education part.

Katnip, RN · Oct 22, 2007

We use BIRP. Behavior, Intervention, Response, and Plan.

I don't like it that much because we also use pre-printed forms and there's not much room on there for much more than one behavior a shift. Kind of odd. I prefer to do a narrative within that format, but with more space.

As far as charting interventions, what did you really say or do related to a particular behavior besides encouraging? Did you explain how it could be helpful to the patient? Just expand a little on each one.

PsychNurseWannaBe, BSN, RN · Oct 23, 2007

can someone tell me how to chart "therapeutically"? asides from using
"encouraged pt to verbalize feelings" what else can i use? i have looked at many charting books but i havent seen anything that helps and the pysch book we are using isnt helpful.

I'm back... :)

I wanted to give a little more concrete info. Basically when you chart for a patient, any patient, it is therapeutic. I am wondering if you are talking about what you can do therapeutically with a client who has mental illness. Basically, your therepeutic interventions.

The above example, "encouraged pt to verbalize feelings" is rather broad... maybe it would help you if you recall what you did to get that patient or client to encourage talking. Did you use reflection, exploring, restating, distraction, maybe you used silence to give the client time to pause and to think about how they are feeling. And if the client just isn't willing to particpate, you still sat with them... that is, offered therapeutic use of self.

1. Encourage client to verbalize feelings by reflecting statements that the client made

2. Utilized therapeutic communication, such as reframing and paraphrasing, and use of self for 20 minutes

3. Help client to reflect on recent events and then asked what are some solutions that may help in the future

4. Encouraged client to use adaptive coping mechanisms and problem solving strategies

5. Offered client several things he could in the day room to pass the time and increase socializing

Even playing a game can be therapeutic... for example, client was experiencing mild to moderate anxiety, distracted client by playing a game of checkers in the day room.

Sometimes our interventions are very subtle, compared to other nursing interventions and specialties. But they are interventions none the less.

Hope that helps

~Psych