NUR 2520C – Psychiatric Mental Health / Psychiatric NursingProcess Recording

Name __________________________________

General Information: Patient’s Initials: Age of Patient: Patient’s Diagnoses:Milieu / Setting / Descriptive Atmosphere:Mental Status Examination:General Appearance:Level of Consciousness:Dress:Facial Expressions:Posture:Level of Understanding:Gait:Grooming:Disheveled:Dressed Inappropriate for Season:Psychomotor Behavior:Activity Level:Eye Contact:Attitude Toward the Nursing:How the Client Arrived on Unit:Mood:Depressed / Sad:Labile:Elated:Expansive:Euphoric:Anxious:Affect:Blunted:Flat:Restricted:Depressed:Excessively Bright:Expansive:Angry / Explosive:Quality of Speech:Clear / Slurred / Aphasic:Rate: Normal / Slow or Latent / Fast:Spontaneous:Talkative:Whispered:Monotone:Mumbles:Loud:Rapid / Pressured:Stuttered:Refuses / Non-Communicative:Perceptual-Sensory Disturbances:Hallucinations: Auditory / Visual / Tactile / Olfactory:

Illusions:

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Thought Content:Compulsions:Delusions: Insertions / Paranoid / Somatic / Jealousy:Phobias:Obsessions:Anxiety Level:Thought Processes:Loose Associations:Flight of Ideas:Phobia’s:Word Salad:Confabulation:Blocking:Disorganization:Higher Brain Function – Mini-Mental Examination:Orientation: Person / Place / Time / Situation:

Memory: Remote / Recent / Recent Past / Immediate Memory / Immediate Recall:

Concentration & Attention:Visio-Spatial Abilities:Abstraction & Proverb:

Impulsivity:Judgment:Insight:Reliability:Psychosocial Assessment:Recent Stressors:

Psychiatric Treatments or Counseling / Psychotherapy:

Quality of Support Systems & Strengths:

Presence & History of Suicidal Ideations, Gestures, & Risk Assessment:

Presence of Homicidal Ideations, Gestures & Risk Assessment:

Present & Past Coping Patterns / Skills:

Self-Concept, Self-Esteem, & Strengths:

Cultural Needs:

Legal History:

Spiritual Assessment:

Using Erickson’s 8 Stages of development: In what stage should the client be according to his/herAge?

What Prior Developmental Stage, if any, seemed to be unsuccessfully resolved by this client?

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Psychiatric Process Recording Care PlanNursing Diagnoses in R/T….AEB…form:

Outcomes for Client Exchange Nursing Interventions Evaluation of Outcomes2 – 3 outcomes (at least one short term

and one long term) for conversation must be client-centered, convey openness of

exchange; They must be timed, measurable, & realistic in the patients’

language & level of functioning.

Nursing interventions are to be independent nurse-centered actions, which assist the patient meet outcomes. They may include assessment, teaching &

collaboration with other disciplines.Minimum of 3 interventions.

Time Interventions – q15, q30, q1hour, qd, qid, Teach on day of admission, during conversation, day of d/c, reinforce PRN, etc.

Was your outcome met? Why or why not? What needs continued evaluation?

Which outcome/s needs to be followed by other Psychiatric Services?

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Verbal Content (In Quotes)Identify (P – Patient) (N – Nurse)

Non-Verbal Content (Body Language & Expressions of Client & Nurse)

Identify Therapeutic / Non-Therapeutic Techniques used. Identify Defense

Mechanisms used by the client.

With Each Exchange; Evaluation the Effectiveness of Your Comments & Suggest

Improvements If Needed

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Verbal Content (In Quotes)Identify (P – Patient) (N – Nurse)

Non-Verbal Content (Body Language & Expressions of Client & Nurse)

Identify Therapeutic / Non-Therapeutic Techniques used. Identify Defense

Mechanisms used by the client.

With Each Exchange; Evaluation the Effectiveness of Your Comments & Suggest

Improvements If Needed

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Verbal Content (In Quotes)Identify (P – Patient) (N – Nurse)

Non-Verbal Content (Body Language & Expressions of Client & Nurse)

Identify Therapeutic / Non-Therapeutic Techniques used. Identify Defense

Mechanisms used by the client.

With Each Exchange; Evaluation the Effectiveness of Your Comments & Suggest

Improvements If Needed

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Verbal Content (In Quotes)Identify (P – Patient) (N – Nurse)

Non-Verbal Content (Body Language & Expressions of Client & Nurse)

Identify Therapeutic / Non-Therapeutic Techniques used. Identify Defense

Mechanisms used by the client.

With Each Exchange; Evaluation the Effectiveness of Your Comments & Suggest

Improvements If Needed

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Rubric for Psychiatric Daily Process Recording

Name: Rubric Grade:Subject: Satisfactory – Meets Competency Unsatisfactory – Does Not Meet Competency

General Information General Information is clearly presented. Milieu / Setting & Atmosphere are described accurate details.

General Information is missing and/or Milieu / Setting & Atmosphere are not described using accurate details.

Clients General Appearance

Clients General Appearance is complete and properly recorded using appropriate descriptors within key prompts.

Clients General Appearance is missing and or inappropriately recorded using inappropriate language with the key prompts.

Grooming Clients Grooming is complete and properly recorded using appropriate descriptors within key prompts.

Clients Grooming is missing and or inappropriately recorded using inappropriate language with the key prompts.

Mood Clients Mood is complete and properly recorded using appropriate descriptors within key prompts.

Clients Mood is missing and or inappropriately recorded using inappropriate language with the key prompts.

Affect Clients Affect is complete and properly recorded using appropriate descriptors within key prompts.

Clients Affect is missing and or inappropriately recorded using inappropriate language with the key prompts.

Quality & Rate of Speech

Clients Quality & Rate of Speech is complete and properly recorded using appropriate descriptors within key prompts.

Clients Quality & Rate of Speech is missing and or inappropriately recorded using inappropriate language with the key prompts.

Perceptual-Sensory Disturbances

Clients Perceptual-Sensory Disturbances is complete and properly recorded using appropriate descriptors within key prompts.

Clients Perceptual-Sensory Disturbances is missing and or inappropriately recorded using inappropriate language with the key prompts.

Thought Content Clients Thought Content is complete and properly recorded using appropriate descriptors within key prompts.

Clients Thought Content is missing and or inappropriately recorded using inappropriate language with the key prompts.

Thought Processes Clients Thought Processes is complete and properly recorded using appropriate descriptors within key prompts.

Clients Grooming is missing and or inappropriately recorded using inappropriate language with the key prompts.

Higher Brain Function Clients Higher Brain Function is complete and properly recorded using appropriate descriptors within key prompts.

Clients Higher Brain Function is missing and or inappropriately recorded using inappropriate language with the key prompts.

Psychosocial Assessment

Clients Psychosocial Assessment is complete and properly recorded using appropriate descriptors within key prompts.

Clients Psychosocial Assessment is missing and or inappropriately recorded using inappropriate language with the key prompts.

Spiritual Assessment Clients Spiritual Assessment is complete and properly recorded using appropriate descriptors within key prompts.

Clients Spiritual Assessment is missing and or inappropriately recorded using inappropriate language with the key prompts.

Erickson’s 8 Stages of Man Evaluation

Developmental Level is correct according to his/her age. Prior Developmental Stage unsuccessfully resolved is documented within framework of key prompts.

Developmental Level is missing and/or prior Developmental Stage unsuccessfully resolved documentation is missing.

Patient Centered Outcome/s

Correctly develops an outcome that is written correctly, are patient-centered, timed, measurable, and realistic and outcomes are written correctly.

Outcome/s are missing and not written correctly, and not patient-centered, timed, measurable, and unrealistic. Outcomes are not written correctly.

Nursing Interventions Selects 3 credible interventions to meet outcomes, interventions are timed, independent, nurse-centered, accurate, and patient specific.

Interventions are missing and/or not credible to meet outcomes, and interventions are not timed, and not independent, and nurse-centered, and inaccurate, and not patient specific.

Evaluation of Outcomes

Evaluation states the results of the nursing intervention. States whether the intervention impacted the problem. Provides a revision if the intervention is determined to be ineffective.

Evaluation fails to state the results of the nursing interventions. Fails to state whether intervention impacted problem. No attempts at revision of intervention are provided.

Verbal Content Verbal content is written using quotation marks and identification of nurse / patient responses are easy to follow.

Verbal content is missing and/or written incorrect not using quotation marks and/or identification of nurse / patient responses are hard to follow.

Identification of Therapeutic / Non-Therapeutic Techniques

Identifies the both therapeutic & non-therapeutic techniques with 3 - 4 errors.

Inaccurately identifies the therapeutic & non-therapeutic techniques utilized with greater than 8 errors.

Identification of Defense Mechanisms utilized by the patient

Patients Defense Mechanisms & Coping Mechanisms are recorded properly using appropriate medical language.

Patients Defense Mechanisms & Coping Mechanisms are missing and/or incomplete and/or recorded improperly using inappropriate medical language.

Evaluation of Effectiveness or Conversation

Evaluation of effectiveness of conversation is stated. Provides documentation of outcomes that need further evaluation. States Strengths & Weaknesses within key prompts

Evaluation of effectiveness of conversation is missing and/or not stated and/or does not identify effectiveness of conversation and/or has missing documentation that the outcomes need further evaluation. Omits 3 or more Strengths & Weaknesses in key prompts

Respect of Human Diversity

Demonstrates most of the time the worth & respect of human diversity (i.e. values, beliefs, & attitudes) by writing appropriate comments showing a non-judgmental attitude & tolerance to the psychiatric patient.

Demonstrates lack of the worth of an individual & disrespects human diversity (i.e. values, beliefs, & attitudes) writing inappropriate comments showing a judgmental attitude and intolerance to the psychiatric patient.

Assignment Due Date Handed in at or before due date. Handed in late.

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