Psychiatric nurses working in inpatient settings are crucial in gathering information that enables psychiatrists to make informed medication decisions.
Their progress notes also facilitate effective communication among other healthcare providers and staff members and serve as evidence of the medical necessity of a patient’s treatment.
If you’re uncertain about how to compose a progress note in psychiatric nursing, this post aims to assist you.
We will discuss important elements that should be included in each progress note, to ensure that the care provided is of high quality and that insurers reimburse for the treatment.
What should the content of a Psychiatric Nurse’s Progress Note Look Like?
A nursing note is a document that outlines the care provided to a patient and their response to it.
Psychiatric nurses should adhere to a standard format and ensure their notes are accurate, clear, and comprehensive.
A sample psychiatric note template may include the following elements:
- Patient’s name and identification number
- Admission date
- Facility Name
- Patient’s date of birth, age, and gender
- Patient’s current mental state
- Compliance with medication regimen
- Side effects or allergic reactions to medication
- Any changes in medical condition
- Nursing interventions provided
- Goals targeted during the intervention
- Patient’s reaction to the intervention
- Laboratory tests ordered
- Vital signs
- Diagnosis
- New medications prescribed
- Reasons for medication changes (if applicable)
- Date and signature
By including these elements in their notes, psychiatric nurses can ensure that they are providing accurate and comprehensive documentation of the care they provide to their patients.
A must-have content of any Psychiatric Nurse’s Progress Note.
Progress notes need to be detailed, but only relevant information should be included.
The following 10 pieces of information are essential for psychiatrists to understand in a nurse’s progress note:
Patient’s Overall Status:
The note should provide an overview of the patient’s current condition, including any changes or issues with their social relationships or situation.
It should also mention if their medication appears to be effective or not.
Symptom Status:
The note should provide information on the status of the patient’s target symptoms, which are closely monitored by the psychiatrist to evaluate treatment effectiveness.
Any changes or new symptoms should be recorded.
Patient’s Behaviors:
Information on the patient’s behaviors during the shift, such as participation in activities, adherence to rules, medication compliance, and appetite should be included.
Any disruptive or aggressive behaviors should be noted.
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Medication Side Effects:
The note should mention if the patient is experiencing any potential side effects from their medication, such as dizziness, increased thirst, or drowsiness.
This is important to alert the psychiatrist of potential severe issues.
Mental Status Examination:
A mental status examination (MSE) is an essential assessment tool that allows nurses to use their observation skills.
It highlights the patient’s current mental state and progress, so psychiatrists can make informed decisions.
The note does not need to include a full MSE but should touch on essential areas such as the patient’s anxiety level, appearance, signs of psychosis, and mood.
Any significant changes in the patient’s mental state and potential risks should be documented.
Special documentation
In certain cases, patients may require special documentation due to specific circumstances.
For instance, individuals who are placed in restraints or seclusion have specific documentation needs as these interventions can pose a health risk and may have legal implications if not used properly.
Documentation for restraint or seclusion typically includes information about the behaviors or circumstances that led to the use of restraints or seclusion, the patient’s actions during the process, interventions provided to the patient, a list of staff members involved in the intervention, and an assessment of any physical injuries. Additionally, some patients may have medical needs that require reevaluation, such as a fall risk assessment for patients who have difficulty walking or standing.
Vital signs
The frequency at which vital signs are obtained may vary depending on a facility’s policy.
These vital signs may include blood pressure, pulse, temperature, and respiration. Additionally
visual acuity and the patient’s height, weight, and body mass index may also be documented.
Nursing interventions
These are an essential part of a patient’s treatment plan, and it’s crucial to document these interventions and the patient’s response to them.
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For example, if medication is administered, the patient’s compliance and response to the medication should be noted. Additionally, if therapeutic interactions occur, it’s essential to document the patient’s engagement and progress toward objectives and goals, as well as their overall response to the therapeutic intervention.
Level of care
The level of care recommended for a patient, such as continued hospitalization or outpatient treatment, should be documented.
It’s important to provide proof of the medical necessity of the recommended treatment through nursing documentation. This information will be required by the patient’s insurance provider and will help the facility prepare for a treatment review.
Progress note
Finally, it’s important to link progress notes to a patient’s treatment plan.
The objectives from the patient’s treatment plan that were addressed should be identified in the documentation, along with the interventions used to achieve goals and the patient’s response to these interventions.
Tips for Writing Mental Health Nursing Notes
To compose well-written progress notes, consider the following tips:
Begin your notes with identifying information such as the patient’s name, age, and birthdate.
Use plain language, avoiding technical terms and acronyms.
Utilize short, clear, and complete sentences.
Avoid incorporating information from other sources into your notes, instead, write it down yourself.
Remember that patients may have access to their progress notes, so it is vital to document accurately and avoid language that may be considered offensive or biased.