Documenting

  1. Hey fellow psych nurses. I am struggling with documentation clients who are severely mentally ill. I often hear many phrases used to describe client status and it begins with hallucinations which can be further specified and delusions which can vary, etc. There are many terms to describe what a patient is experiencing. But I often do not directly hear or see when these things happen and hear about it through my fellow team. I know we are not supposed to document things we did not observe ourselves. But where does that leave me if I say I did not observe these from lets say a schizophrenic client? Does it look like the client is ok and improving? I try to just note the behavior I have observed that shift. I'm trying to be a better psych nurse but it's difficult when you don't always know what is going on in the client's head. I work with clients who are severely mentally ill, inpatient.
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    About nina12345

    Joined: Dec '17; Posts: 29; Likes: 6

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  3. by   Sour Lemon
    Quote from nina12345
    Hey fellow psych nurses. I am struggling with documentation clients who are severely mentally ill. I often hear many phrases used to describe client status and it begins with hallucinations which can be further specified and delusions which can vary, etc. There are many terms to describe what a patient is experiencing. But I often do not directly hear or see when these things happen and hear about it through my fellow team. I know we are not supposed to document things we did not observe ourselves. But where does that leave me if I say I did not observe these from lets say a schizophrenic client? Does it look like the client is ok and improving? I try to just note the behavior I have observed that shift. I'm trying to be a better psych nurse but it's difficult when you don't always know what is going on in the client's head. I work with clients who are severely mentally ill, inpatient.
    A patient's behavior can vary widely from shift to shift. You're correct that you should document what you observe. In some cases, I document "unable to assess" for hallucinations and/or delusions. It's often accompanied by observations that the patient is guarded or withdrawn, but not always.
  4. by   elkpark
    Are you asking the client directly about any hallucinations as part of your assessment? For example, "Are you hearing the voices today? Are they voices, or are you just hearing noises? What are they saying? Are they speaking directly to you, or just talking among themselves? Is there anything different about them today? Are they telling you to do anything (command hallucinations)? Are they more or less than yesterday?" Etc., etc. When we talk about charting what we observe, that doesn't mean you just literally observe, without taking an active role in gathering data. The best way to "know what is going on in the client's head" is to ask the client.

    Best wishes!

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