Psych charting

Specialties Psychiatric

Published

Recently, my facility is changing the format they require for nursing notes. If we can offer an alternative to their suggestions, we may get them to bite. Any suggestions on a effective format.?

Specializes in psych, addictions, hospice, education.

I don't think it's necessary to quote expletives unless they convey a bigger picture that saying something like "pt swore at peer, using threatening words". That being said, it's almost always better to quote rather than say something that might come off as subjective rather than objective.

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Specializes in telemetry, med-surg, home health, psych.

no, none of us received much teaching re: charting in psych...I agree, you just learn as you go.....I always think it is a good idea to "quote" pts. remarks, especially if it helps to show their behavior or status...also helps doc to read the quotes, too...

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Specializes in Psych, ER, Resp/Med, LTC, Education.

I am in a psych ER now so don't have to deal with this any longer--thank god! But when I was on inpatient psych we had 10 patients each and they did a preprinted thing where you checked and circled, etc when I first started but people rushed they said and didnt chart accurately--I liked it......they changed then to SOAP and 10 soap notes is A LOT to write!!! Especially when its every single shift. I found that some patients I could write what was needed in a few sentances......the patient who did fine, took their meds and you did little for besides hand them their meds.....unfortuanely when you have 10 patients each the squeeky wheel gets the grease! So on a couple of patients you might have 2 pages worth of crap to write then the others you have to try to remember who the hell they even are!! LOL Thank god for wonderful techs! So I eventually said the hell with it I'm writing a narative and just be happy all 10 notes are done!! lol --seriously you have the patient you literally says four words all shift and behaves and what the hell do you write for subjective......"Thanks". (for the pills) and "when is lunch?" yeah I write that and well that is really worthe writing.... or reading!! LOL

God I do not miss that stuff.......now I do the initial evals when they first get to the hospital. That is a short narative and the rest 6 pages of forms.

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Specializes in telemetry, med-surg, home health, psych.
I am in a psych ER now so don't have to deal with this any longer--thank god! But when I was on inpatient psych we had 10 patients each and they did a preprinted thing where you checked and circled, etc when I first started but people rushed they said and didnt chart accurately--I liked it......they changed then to SOAP and 10 soap notes is A LOT to write!!! Especially when its every single shift. I found that some patients I could write what was needed in a few sentances......the patient who did fine, took their meds and you did little for besides hand them their meds.....unfortuanely when you have 10 patients each the squeeky wheel gets the grease! So on a couple of patients you might have 2 pages worth of crap to write then the others you have to try to remember who the hell they even are!! LOL Thank god for wonderful techs! So I eventually said the hell with it I'm writing a narative and just be happy all 10 notes are done!! lol --seriously you have the patient you literally says four words all shift and behaves and what the hell do you write for subjective......"Thanks". (for the pills) and "when is lunch?" yeah I write that and well that is really worthe writing.... or reading!! LOL

God I do not miss that stuff.......now I do the initial evals when they first get to the hospital. That is a short narative and the rest 6 pages of forms.

How 'bout charting on 25 pts.???? We have one nurse for up to 25, then 2 nurses for up to 40....

Needless to say, my charting is slim.......unless there is a real problem to chart about....Ours is checks and circles but then you have to chart to address the treatment plan also......UGH !!!!

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Specializes in Psych, ER, Resp/Med, LTC, Education.

25 patients? In an acute care unit? Or is that more of a long-term psych facility? The ratios are different for acute care vs. long term aren't they? And you don't have to chart everyday in long term care I though......once a week is what I thought, of course if you have a patient that has something go on on a particular day or days you would have to chart that..........but. Maybe psych long term is different than medical long term. I never worked psych long term, only medical SNF/LTC. charting on and being responsible for 25 ACUTE psych patients can't be safe and I can't imagine OMH would okay that..........????

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Specializes in telemetry, med-surg, home health, psych.
25 patients? In an acute care unit? Or is that more of a long-term psych facility? The ratios are different for acute care vs. long term aren't they? And you don't have to chart everyday in long term care I though......once a week is what I thought, of course if you have a patient that has something go on on a particular day or days you would have to chart that..........but. Maybe psych long term is different than medical long term. I never worked psych long term, only medical SNF/LTC. charting on and being responsible for 25 ACUTE psych patients can't be safe and I can't imagine OMH would okay that..........????

we are a private hospital...our pts. stay anywhere from 7 days to 4 weeks..(dep. on their ins. and needs)

we chart q. day on all.....we usually have 3-4 MHT's so that helps a lot.....and a med nurse (LPN) that gives the meds.....so we basically do admits, groups, interview each and chart, attend tx. team meetings, etc. etc......

some days OK, some are wild.......

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Specializes in Psych, ER, Resp/Med, LTC, Education.

Wow, thats interesting. With the LOS you mentioned it sounds like an acute facility. Are you funded and monitored by OMH or no because you are private? So you have two nurses RN, LPN, and 4 techs --6 people for 25 and 7 for 40......hmmmm......interesting. So in numbers over all it isn't too much different then where I was --tough they were suppose to have 5 nurses for 30 and 2-3 techs but always ran on 3 nurses due to shortage. So even the charge had 10. You just have less nurses and more techs and in a restraint it doesnt matter much. But for charting and meds yuck!! You poor nurses. .................I find it interesting to see how other facilities run to see what is worse and what is better! LOL

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Specializes in telemetry, med-surg, home health, psych.

no, sometimes only one RN if census is under 25....sometimes two...

I have had 40 pts. with only 2 MHT's....if there are no 1 on 1's or LOS it is manageable....if we have 3 LOS and 1 one on one, it is tuff....once I got someone from housekeeping to do a LOS, we were desperate !!!

3 nurses for 30....were they all RN's or was that counting the med nurse?

yes, the charting is hellacious at times....

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I need a example of birp notes on on a defiant child i am lost

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Specializes in psych, addictions, hospice, education.

I can't give you an exact note, since you haven't given us much info, but here are some hints:

B = Behavior What is the child doing that would indicate a problem or an improvement in whatever the focus of treatment is?

I = Intervention What did you do or other staff members do about the behavior?

R = Response What was the child's response to what you or the other staff members did?

P = Plan What will you do next or what can you guarantee others will do next, to help with what you're charting about or to help the child improve?

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I'm in the same boat as Aloevera. Private hospital, 26 patients, acute, 1 RN, 1 LPN. We're being "encouraged" to change our documentation from a narrative of how they were doing (both positive and negative) to focusing just on behaviors that support their being in the hospital. I'm uncomfortable with this as it encourages "fudging" the report.

For example - a suicidal patient now contracts for safety, denies SI, participated in group and individual therapy, and is compliant with meds, etc. BUT it's only been 4 days since the attempt. How can you document that s/he needs more time without making something up?

While we're at it, has anyone ever seen a list of "action" words that are appropriate for psych documenting. My brain goes numb after too many "displays ...." or "denies..."

BTW, I HATE DOCUMENTATION. :sstrs: I know it's important but when I have to spend the last 2 hours of my day with pen and paper struggling to find something to say rather than spending time with patients I get a little cranky.

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Me too,,, New nurse and need help with psych documentation BIRP. there has to be a website or book or so, something!

So what was the outcome>

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