Documentation in Psychiatric Nursing Practice
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Transcript of Documentation in Psychiatric Nursing Practice
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Hazel May N. Evangelista, RN MAN
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(a systematic approach totreatment) is relevant inpsychiatric nursing practice.
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` Patient-centered
` Goal-directed action that facilitates healthpromotion
` Primary prevention
` Treatment
` Rehabilitation
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`Assessment
`
Diagnosis`Planning
`Intervention`Evaluation
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` Assessment (S-O- significant diagnostic findings)
` Diagnosis (NANDA-based) as manifested by
` Planning( 8 hour plan, however, 4-6 days is morerealistic as short-term plan in psychiatric cases)
` Intervention (with rationale)
` Evaluation as evidenced by
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1st
PATIENTS HISTORY
2nd
MENTAL STATUS ASSESSMENT
3rdPHYSICAL EXAMINATION
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` It is the identification of patients problems basedon conclusions about the dynamics evident inverbalizations and behaviors.
` SAFETY is a priority.
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Potential or actualproblems
Contributing orcausative factor
Defining characteristicsor behavioral outcome
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stressors
losses
Past
experiences
Developmentalissues
Environmental
circumstances
Relationshipissues
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` Includes verbal and non-verbal cues that reflectspatients actual or potential problems
` These are the focus of nursing intervention,behaviors that it would be helpful to change
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` (Problem) related to (contributing factor) asmanifested by (behavioral outcome)
`Anxiety, moderate, relatedto marital problems as
manifested by ineffectiveproblem solving
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`It specifies an adaptive
behavior to replace one that isdysfunctional.
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UNREALISTIC REALISTIC
` Expecting patientsto change anegative self-image to a positiveself-image duringa short inpatientstay or outpatient
program
` Asking patients towrite a list of theirstrengths, abilities,and a positivequalities
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` It involves a few hands-on activities other thanminor treatments, monitoring vital signs, andgiving medications
` FOCUS: verbal strategies that are used to guidepatients in solving problems for themselves and inachieving outcomes
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`Medical diagnosis do notinclude in any of the three
parts of the diagnosticstatement
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`Evaluation of patient progressis a foundation for discharge
planning and for referrals toother services within the
continuum of care
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`
Problem Oriented Recording(FDAR)
`SOAP
`Narrative Recording`Process Recording
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`Components are basically thesame:
Patients statementsNurses observations
Analyses
Plans
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` Audiotape or videotape recordings are moreaccurate
` It is a record of an encounter with a patient that isas a verbatim as possible
` Recording generally includes verbal answers
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` SUBMIT MIDTERM PROJECT: Movie Analyses
` BRING YOUR OWN NANDA BOOK ONEXAMINATION DAY
` YELLOW PAPER` GREEN BALLPEN/BLACK BALLPEN
` PERMIT
` FRIDAY: JANUARY 27, 2012
` SEC 2- 4TH FLOOR/ 7:30-9:00AM` SEC 1- 4TH FLOOR/ 9:00-10:30AM