UT-Harris County Psychiatric Center
of Last Review: 7/19/12
SME: Chief Nurse officer
Nursing documentation entries are a legal record of the patient's assessment, reassessment and treatment progress. This documentation is a means of communicating information to the treatment team and is important for quality patient care. Nursing entries may be written by the following caregivers: R.N., L.V.N. and Psychiatric Technicians.
Policy: It is an expectation that each patient has two (2) progress notes, in addition to a sleep note, everyday.
1. The RN is responsible for documenting a patient assessment/reassessment for every shift (i.e., 7-3, 3-11, 11-7, 7a-7p and 7p-7a) on the Nursing Progress Notes during the patient’s entire stay with the exceptions of Unit 1D (subacute). Components of the progress notes include:
|Medication Compliance and Response Treatment|
|Subjective and Objective Data|
|Physical Assessment- Review of Symptoms|
|Response to Intervention|
|Sleep Hours/Additional Data (11-7 Progress Notes)|
2.Special Shift Documentation for Four Hour Shifts:
2.1 Staff assigned to work 3p-7p who are relieved by 7p-7a staff, are expected to document 'by exception' (i.e., psychiatric/medical emergencies, special incidents, physician notifications, stat lab, and family communication/contact). This information may be documented in the Nursing Addendum Note. The staff who work 7p-7a are expected to document a full progress note, in addition to a sleep note, for all patients assigned on the team.
2.2 Staff assigned to work 3p-7p,who are relieved by 7p-11p staf,f are expected to document a full progress note on 1/2 of the patients assigned on the team. The nurse relieving from 7p-11p is expected to complete a full progress note on the remaining 1/2 of the patients assigned on the team.
2. The Discharge Instruction may be considered the Nursing Flow Sheet entry for the shift on which the patient is discharged. Note on the Nursing Addendum Note – “See Discharge Instruction.”
3. A Nursing Note Addendum may be utilized any time during the 24-hour period once the minimum documentation entry is met. Narratives may be utilized to capture information such as team meetings, requests for release, letter of retraction, patient/family complaint, medical complications, and administration of NOW/STAT medication, combative/destructive behavior and any other significant occurrence.
4. Seclusion/restraint documentation is documented on the Nursing Seclusion/Restraint Progress Notes.
Sub acute Unit Nursing Progress Notes
1. For the first 7 days post admission, nursing progress notes are completed each shift.
1.1 Patients on suicide precautions require a Nursing Progress every shift.
2. Beginning on the 8th day, a single nursing progress note is documented on the 7-1 or 3-11 shifts daily as well as a nightly 11-7 Progress
2.1 Patients on precaution(s) with the exception of suicide precautions require a Nursing Addendum note on the shift which the Nursing Progress note is not completed.
3. Patient on precaution(s) with the exception of suicide precautions require a Nursing Addendum note on the shift which the Nursing Progress note is not completed.
4. A Sub acute Weekly Progress Summary may be completed in lieu of a Nursing Progress and a Master Treatment Plan Review.
The Joint Commission-Provision of Care, Treatment, and Services
Center of Medicare/Medicaid Services (CMS) Conditions of Participation