Documentation in Psychiatric Mental Health Nursing

Critical pathways care plans

Structured plans guiding patient care steps.

Kardexes

Quick reference for patient care information.

Flow sheets

Visual records of patient data over time.

Progress notes

Document ongoing patient assessments and care.

Discharge/transfer forms

Documents patient status during transitions.

Acute care documentation

Focuses on immediate patient needs and interventions.

Long-term care documentation

Emphasizes ongoing patient management and support.

Home health care documentation

Records care provided in a patient's home.

Prohibited abbreviations

Terms that cannot be used in documentation.

Client data reporting guidelines

Standards for accurate and ethical data sharing.

Confidentiality measures

Protocols to protect patient information security.

Legal recording standards

Requirements for valid and reliable documentation.

Assessment

Collection of subjective and objective patient data.

Diagnosis

Determines appropriate nursing interventions for patients.

Electronic health records (EHRs)

Digital systems for managing patient health information.

Evaluation

Assessment of patient responses to interventions.

Interventions

Nursing actions addressing patient problems.

Objective data

Observable information measured through senses.

Planning

Development of care goals and strategies.

Record

Formal document evidencing patient care.

Recording

Process of documenting patient care activities.

Revision

Updates to care plans based on evaluations.

Subjective data

Information reported by the patient.

Communication

Facilitates information sharing among health professionals.

Planning Client Care

Uses client data to develop tailored care plans.

Auditing Health Agencies

Reviews client records for quality assurance.

Accrediting Agencies

Evaluates compliance with health agency standards.

Research

Utilizes client records for data-driven studies.

Education

Serves as a learning tool for health students.

Reimbursement Documentation

Ensures correct coding for Medicare payment.

Legal Documentation

Client records can be used as court evidence.

Health Care Analysis

Identifies needs for hospital service utilization.

SOAP Method

Framework for organizing patient information.

SOAPIE Method

SOAP format that includes interventions and evaluations.

DRG Codes

Diagnosis-related group codes for billing.

Quality Assurance

Ensures standards in health care delivery.

Client Record

Document containing comprehensive patient information.

Health Professionals

Individuals providing care in health settings.

Focus Charting

Centers on client concerns and strengths in care.

DAR

Framework for progress notes: Data, Action, Response.

Data (D)

Observations of client status and behaviors recorded.

Action (A)

Nursing actions planned and implemented for care.

Response (R)

Client's reaction to nursing and medical interventions.

ADPIE Method

Framework for nursing process: Assessment, Diagnosis, Planning, Interventions, Evaluation.

Assessment (A)

Subjective and objective data supporting identified problems.

Diagnosis (D)

Guides interventions using NANDA format: problem, etiology, symptom.

Planning (P)

Specific orders to manage client problems and goals.

Interventions (I)

Nursing actions relevant to client problems.

Evaluation (E)

Assesses client response to nursing interventions.

Client Database

Comprehensive record of client information and care.

Bedside Documentation

Immediate care recording at client's location.

Documentation Principles

Standards for high-quality nursing documentation.

Accessible Documentation

Easily retrievable information for nursing staff.

Accurate Documentation

Correct and relevant details in client records.

Auditable Documentation

Records must be verifiable and traceable.

Clear Documentation

Concise and understandable entries in records.

Timely Documentation

Records created promptly after care is given.

Reflective Documentation

Shows the nursing process in client care.

Comprehensive Education

Training nurses on documentation policies and procedures.

Global Documentation System

A unified system for managing patient documentation.

Computer Competence

Ability to effectively use computer hardware.

Software Proficiency

Skill in using documentation software systems.

Organizational Policies

Rules governing documentation practices in healthcare.

Downtime System

Alternative documentation method during electronic failures.

Protection Systems

Built-in security measures for documentation systems.

Data Security

Safeguarding sensitive information from unauthorized access.

Patient Identification Protection

Ensuring confidentiality of patient identities.

Confidentiality Standards

Maintaining privacy of patient and professional information.

Documentation Entries

Records must be accurate, valid, and complete.

Entry Authentication

Verification of author identity and entry integrity.

Time-Stamps

Recording date and time of documentation entries.

Legibility Requirement

Entries must be clear and readable.

Standardized Terminologies

Uniform terms for effective data aggregation and analysis.

Nurse Accountability

Responsibility for documenting personal patient care.

Chronological Documentation

Recording client information in time order.

Error Correction

Addressing documentation mistakes promptly and transparently.

Late Entry Notation

Recording late entries with appropriate timestamps.

Signature Requirement

Nurse must sign and title each documentation entry.

Privacy Safeguarding

Protecting clinical records through secure storage.

Contemporary Knowledge Update

Staying informed on current documentation practices.