Writing progress Notes in Psyc

[caribbeanbeauty]

Hello everyone;

I am new to psyc and trying to learn as best as I can. I think I am doing fair well with interviewing the patients on my unit. I am wondering if someone could stair me in the right directors or give some good resourses for writing good notes after interview the patients.

[aloevera]

We always chart in accordance to the Treatment plan problems....and of course, there are guidelines on the notes to answer to

If there are any statments made by the pt. that the Dr. should be aware of, or anything you deem important, any medical problems that need to be addressed, etc. You can never write too much on a progress note !!

[Andrew, RN]

Mood, affect, facial expressions, body language, posture, what the patient says, how they say it. Their behaviors. etc....

[Meriwhen, ASN, BSN, MSN, RN]

Be sure to address any sucidial or homicidal ideations as well.

[pinkiepie_RN]

I try to address the following in my notes:

• SI/HI
  
• AH/VH
  
• safety
  
• anxiety
  
• need for PRN medications
  
• affect
  
• behavior
  
• group attendance
  

[caribbeanbeauty]

Thank You very much..this is great info....

[Whispera, MSN, RN]

Your facility might have a specific format it uses for notes. Some use SOAP (subjective, objective, assessment, plan)charting. Some use DIRP (data, interventions, response, plan). Ask around and look at the charts to see what's there. I had worked several months before anyone told me that I should be using a specific format, and then I did notice it in others' charting. It's one of those things that sometimes doesn't get covered enough in orientation.

[caribbeanbeauty]

Thank you all for your wonderuful and very insightful information. This has been very helpful. Thanks a million!