Psychiatric charting help

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Specializes in psychiatric/behavioral.

Hello Allnurses world! I graduated in May and started my career as a psychiatric nurse. I have minimal charting experience from school and was wondering what are some good resources to get better at charting?

Is there some sort of template to use as a general outline for key observations or terms that need to be included in the daily progress notes? I thank you all for the help!

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Specializes in Psych, Addictions, SOL (Student of Life).

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

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Specializes in psychiatric/behavioral.

Thank you very much for your help! Your post was very informative and you presented a great example, thank you!

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Hi. We have an EMR which requires a mental status assessment (checksheet) to be done separately, which includes orintation, mood, affect, thought contant etc. I then do my sift note. My standard note template is as follows. I change the below as needed and add on as needed:

Patient is pleasant, visible, social. +dinner, +groups.

-SI/HI, -AH/VH. +Depression, +Anxiety. ADLs

Room safety check performed.

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Specializes in Psych, Addictions, SOL (Student of Life).
36 minutes ago, tapeitup said:

Hi. We have an EMR which requires a mental status assessment (checksheet) to be done separately, which includes orintation, mood, affect, thought contant etc. I then do my sift note. My standard note template is as follows. I change the below as needed and add on as needed:

Patient is pleasant, visible, social. +dinner, +groups.

-SI/HI, -AH/VH. +Depression, +Anxiety. ADLs

Room safety check performed.

I like it and we used to do it that way but we had a federal survey and the surveyors said we also had to include this information in the narrative. I just love redundancy in medicine!

Hppy

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Specializes in retired LTC.
3 hours ago, tapeitup said:

.

-SI/HI, -AH/VH. +Depression, +Anxiety. ADLs


Please translate for those of us not too psych saavy. TY

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Specializes in Psych, Addictions, SOL (Student of Life).
50 minutes ago, amoLucia said:

Please translate for those of us not too psych saavy. TY

SI = Suicidal ideation

HI = Homicidal Ideation

GD= Gravely disabled by reason of mental illness

AH= auditory Hallucinations

VH= Visual Hallucinations

There are also TH (Tactile hallucinations) And OH (Olfactory Hallucinations)

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Specializes in retired LTC.

Zipping around, I figured out SI. TY

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Hi all thanks for the info. How about for thorough Mental state examination. Any tips. Im a new psych nurse.

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Specializes in Psych, Addictions, SOL (Student of Life).
5 hours ago, Yuan said:

Hi all thanks for the info. How about for thorough Mental state examination. Any tips. Im a new psych nurse.

Here's a link to the mini mental status exam- I base a lot of my assessments of these type of questions

https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&noSaveAs=1&Rendition=Primary&allowInterrupt=1&dDocName=dhs16_159601

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Extremely helpful. Thanks a lot hppy.

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On 8/14/2020 at 8:52 PM, hppygr8ful said:

The link is not opening. Please Help!

Here's a link to the mini mental status exam- I base a lot of my assessments of these type of questions 

https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&noSaveAs=1&Rendition=Primary&allowInterrupt=1&dDocName=dhs16_159601

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