10 things that should be in every psychiatric nurse's progress note

In-patient psychiatric nurses play an important role as information collectors so that, among other things, prescribers will make the right medication decisions.

Here are ten pieces of information that a prescriber would like to read in a nurse's note. This information should be in at least one nursing progress note per shift.

               

Nursing Progress Note Example

  1. Overall, how is the patient? Better, same, worse?
  2. What is the status of the "target symptoms"?  These are the signs and symptoms the prescriber is watching to determine how treatment is progressing. Are the target symptoms still present? In your opinion, are they better, the same, or worse? Why?
  3. Information about basic behaviors during the shift, like attendance at activities, appetite, compliance with rules, medication compliance. This will certainly tell the prescriber something about the patient´s progress and state of mind.
  4. Are there any reports or signs of possible side effects of the medication? They do not need to be labeled as possible side effects, but drowziness, unsteady gait, dry mouth, and other such symptoms should be documented.  This is particularly important. It alerts the prescriber to potentially serious problems.
  5. A mental status examination. It need not be a full MSE, but a few basic areas should be touched on. What is the patient´s appearance? Any psychotic process? Any anxiety? What does the mood seem to be? This again highlights the patient's status and progress, but also permits the nurse's powers of observation to be utilized.
  6. Special Circumstances: Some patients have special documentation requirements. Patients in restraints or seclusion, for example. (These patients are at medical-legal risk and have special documentation requirements.) Some patients have medical needs, or need to be re-evaluated with, for example, a Fall Assessment for a patient who has become unsteady, or a patient who needs a body search.
  7. Vital Signs. How often these need to be obtained depends on hospital policy.
  8. Nursing Interventions.  Was medication administered, compliance noted, effects monitored? Was the patient engaged and encouraged? Did a therapeutic interaction occur? Nursing interventions are part of the treatment plan.  Did they occur during the shift?  If so, they should be documented.
  9. Level of Care: Nurse should opine on reasons, or not, that patient requires continued hospitalization. This means a lot to utilization reviewers and insurance companies need to hear it.
  10. Link to Treatment Plan: Most progress notes should be linked to the treatment plan. Plan your work and then work your plan. This is a good clinical practice and is very highly appreciated by surveyors.
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