New grad/psych nurse. Anyone have examples of good notes?

  1. Here's what I stuck in my palm pilot for an admission note. Let me know if anyone has any suggestions or a good example of a regular daily note, or discharge note. Thanks.

    Admission Note

    Time of Admission, Awake, Alert, Oriented? Where from --> going to? Ambulating? How well?
    Placed on CO. Vitals. See nursing assessment form. Calm/Cooperative? Assess SI/HI. Contract for safety. Thought process? Flight of ideas?
    Mood. Allergies? Signed for receipt of bill of rights. Oriented to unit. Reviewed schedule and encouraged to attend groups. Physical problems?
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    About njmonsterboi80

    Joined: Dec '03; Posts: 44; Likes: 2


  3. by   drumwhacker
    Well..... All of my daily notes are individualized, but I always include something about monitoring for safety, encouraging verbalization, patient affect/mood/specific comments and behaviors, and education. We also have a daily MSE form that's completed by an RN. Since my primary job at the moment is nursing groups, it's usually relatively easy to come up with relevant info to chart. It's important to include specific things the patient says or does, especially as they relate to his/her medical/nursing diagnoses. Your interventions and patient response to them are also essential.

    Best Wishes!