documentation in psychiatric nursing practice

8/3/2019 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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Àssessment

`

Diagnosis`Planning

ÌnterventionÈvaluation


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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

documentation in psychiatric nursing practice

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