Documentation in Psychiatric Nursing

Documentation in Psychiatric Nursing PracticeEmillie Grace D. Tombucon RN

•Problem Oriented Recording•SOAP•Narrative recording•Process recording

Problem-Oriented Record•   (POR) a method of patient care record

keeping that focuses on specific health care problems and a cooperative health care plan designed to cope with the identified problems.

• A system of record keeping in which a list of the patient's problems is created and relevant medical history, physical findings, laboratory data, medications, and treatments are listed under the appropriate medical problem.

• Synonymous to intake interview( http://medical-

dictionary.thefreedictionary.com)

The components of the POR are: 

a. Data Base- which contains information required for each patient regardless of diagnosis or presenting problems

b. Problem List- which contains the major problems currently needing attention

c. Plan- which specifies what is to be done with regard to each problem

d. Progress Notes- which document the observations, assessments, nursing care plans, physician's orders, etc., of all health care personnel directly involved in the care of the patient. 

•Example: Page 140 Box 12-3

SOAP

•a device for conceptualizing the process of recording the progress notes in the problem-oriented record.

•Aka Progress Note

•S -indicates subjective data obtained from the patient and others close to him;

• O-designates objective data obtained by observation, physical examination, diagnostic studies, etc.; 

•A- refers to assessment of the patient's status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems; 

•P- designates the plan for patient care.

Narrative•Narrative report is to describe something. • Is told from a particular point of view. • Its makes and supports a point. • Is filled with precise detail. •Chronological, baseline charted every shift

•Lengthy and time consuming

•Source-oriented

Process recording

•a system used for teaching nursing students to understand and analyze verbal and nonverbal interaction.

•The conversation between nurse and patient is written on special forms or in a special format.

The student nurse is instructed to record :•Observations•Perceptions•Thoughts•Feelings•Conversations.

•The student also is asked to:•Analyze his or her communication•Determining and naming both therapeutic

and non-therapeutic techniques used within an interaction.

•The process recording is then studied by the nursing instructor to discover patterns of difficulty in communicating with the patient and to help the student nurse identify them.