by Richard Morganstern, MD
Inpatient psychiatric nurses play an important role as information collectors so that, among other things, psychiatrists will make the right medication decisions. Here are ten pieces of information that psychiatrists would like to read in a nurse’s note. This information should appear in at least one nursing progress note per shift.
(1) Overall, how is the patient? Better, the same, or worse?
(2) What is the status of the “target symptoms”? That is, the signs and symptoms the psychiatrist is monitoring to determine how treatment is progressing. Are they 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, and medication compliance. This will certainly tell the psychiatrist something about the patient’s progress and state of mind.
(4) Any reports or signs of possible side effects of the medication? They do not need to be labeled as possible side effects, but drowsiness, unsteady gait, dry mouth, and other such symptoms should be documented. This is particularly important. It alerts the psychiatrist 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, have special documentation requirements because they are at medical-legal risk. 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? They should be documented.
(9) Level of Care. Nurses should opine on reasons, or not, that the 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.
ICANotes’ specialized EHR software enables behavioral health clinicians to see more patients each day by easing the regulation and documentation burden, allowing them to focus on the reason they got into practice in the first place: to care for their patients’ mental health. Watch this video demonstration to see how a psychiatric nursing note is created in ICANotes.