UT-Harris County Psychiatric Center
Nursing Procedures
Date
of Last Review: 5/19/08
SME: Associate Director of Nursing
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 Psych.
Techs. All entries are in black
ink. No blank spaces are to appear
between chart entries. No
"white-out" or liquid paper is used in the medical record. In case of error, a single line is drawn
through the entry, with the word "ERROR" printed above the entry with
the initials of the person making the error. Signatures must be legible;
include first and last name, title and degree as appropriate.
1.
The RN is responsible for documenting a
patient assessment/reassessment on the 7-3 and 3-11 or 7A-7P and 7P-7A shifts
on the Nursing Flow Sheet during the patient’s entire stay. Components
of the flow sheet include:
·
·
Risk Assessment
·
Medication
Compliance and Response
·
Subjective
and Objective Data
·
Additional
Information
·
Physical
Assessement - Review of Systems
·
Pain
Assessment
·
Intervention
abd Education
·
Response
to Intervention
2.
The Initial
Nursing Assessment may be considered the Nursing Flow Sheet entry for
the shift on which the patient is admitted. Note on the Nursing
Note Addendum – “See Initial Nursing Assessment.”
3. 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.”
4.
11-7 licensed staff documents the Sleep Note in a D-I-R
format.
Late chart entries are labeled “Late entry.”
Include the date and time of the actual occurrence in the body of the
note.
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
from:
·
Team meetings
·
Families
·
Test results
·
Outings
·
Passes
·
Request for release
·
Letter of retraction
·
Patient education
·
Combative/destructive behavior
·
1:1 supervision
·
Direct observation
·
Suicidal ideation/attempt
·
Medical conditions/complications/injuries
·
Detoxification regimen
·
Administration of NOW/STAT medication
·
Any other significant occurrence
Note: Seclusion/restraint is documented on the Seclusion/Restraint
Checklist and Nursing
Seclusion/Restraint Progress Notes.
Related Standard:
JCAHO PE 4.3, TX 1.3