Documentation in Psychiatric Nursing Practice

These flashcards cover key concepts related to psychiatric nursing practice, documentation, and mental health interventions.

Documentation

Anything written or electronically generated that describes the status of a client or the services given to that client.

Problem-Oriented Recording (SOAP)

A method of patient care record-keeping that focuses on specific health care problems and a cooperative health care plan.

S - Subjective Data

Data obtained from the patient and others close to them.

O - Objective Data

Data obtained by observation, physical examination, diagnostic studies, etc.

A - Assessment

The analysis of the patient's status and possible interaction of problems.

P - Plan

Specifies what is to be done regarding each problem identified.

Progress Notes

Documentation of observations, assessments, nursing care plans, physician’s orders, etc. of all healthcare personnel involved.

Narrative Recording

A chronological report describing interactions, observations, and interventions related to a client.

Process Recording

A tool used for nursing students to analyze verbal and nonverbal interactions with patients.

Cognitive Behavioral Therapy (CBT)

Therapy focusing on changing faulty thinking patterns and behaviors.

Electroconvulsive Therapy (ECT)

A medical procedure that uses electrical currents to induce seizures to treat severe psychiatric disorders.

Antidepressants

Medications used to relieve the symptoms of depression and anxiety.

Anxiety Disorder

A condition characterized by excessive worry and fear affecting daily functioning.

Panic Disorder

Recurrent and unexpected panic attacks causing physical and emotional distress.

Obsessive-Compulsive Disorder (OCD)

A condition characterized by unwanted obsessions and compulsions that interfere with daily life.

Crisis

A turning point in an individual's life resulting in overwhelming emotional responses.

Ego Defense Mechanisms

Psychological strategies used to cope with anxiety and protect the self from emotional pain.

Personality Disorder

Enduring patterns of thought and behavior that deviate from cultural norms and impair functioning.