Student Name

DATA COLLECTION
TOOL
Inpatient Mental Health

DATE OF ADMISSION: DATE OF CARE:

AGE: GENDER: Male/Female RACE: African-American, Asian Educational Level/Occupation:
Hispanic/Non-Hispanic American-Indian, White, Other: Hobbies/Interests: (enjoyments):
SYMPTOMS & Behaviors Day of Admission: (Danger Self/Danger Others) Disabilities:
Living Arrangements (# in household):

(AXIS I) PSYCH DX: Legal Guardian (if minor or vulnerable adult):

(AXIS II) (Personality d/o, mental retardation) Advanced Directives/Living Will/Medical Power of Attorney:
CODE STATUS:
(AXIS III) ACUTE/CHRONIC DISEASES/HEALTH HX: No Code, Full Code,
Include any surgical procedure. Partial Code (meds only, SAFETY CONCERNS YES NO
CPR only) FALL RISK
(AXIS V) GAF: BED ALARM ON
(AXIS IV) RECENT STRESSORS (LIST SPECIFIC STRESSORS): SEIZURE PRECAUTIONS
RESTRAINTS

Equipment: VITAL SIGNS Admission Last Recorded Activity Level: Up Ad Lib, BR, BRP, BSEC, Unable to move self
Blood Pressure Hygiene/Bathing: Self Care, Assistance, Total Care
IV’s: Heart Rate/Pulse Elimination: Void/Foley/Ostomy/Dialysis
Respiratory Rate DIET: Supplements:
Dressing Change Orders Temperature Dentures (full or partial), no teeth, teeth poor condition, dysphagia
(list any drains/wounds Intake/Output SLEEP QUALITY: # hrs _____, difficulty falling asleep, difficulty
present and care): Height/Weight staying asleep, early awakening, hypersomnia, nightmares/terrors
Treatments: MEDICATIONS (current):
PT/OT/ST/RT/MSW or Other Referrals:
Home Medications:
Substance Abuse History: Drug(s) of Choice:
Date of Last Use: How much? OTC/Alternative Meds:
How often used in past week/month? PAIN: acute/chronic Intensity: Scale 1-10 Location:
Longest period without use: Characteristics:
Number admissions treatment:
CAGE: ALLERGIES:
PSYCHIATRIC DIAGNOSIS (Axis I, Axis II)
PAGE 2

THIS PAGE IS the TEXTBOOK PICTURE of the selected DSM-IV Diagnosis

COMPLETE FOR ADMITTING PROBLEM (harm to self or others)
PATHOPHYSIOLOGY DSM-IV TR Management/Treatment Nursing Diagnoses with Nursing Interventions
ETIOLOGY Diagnostic Criteria Pharmacology/Therapy Selected Outcomes
*Include risk factors Management Commonly This is textbook picture of Include cultural/ethnic/race
Any cultural/ethnic factors Prescribed for Diagnosis the diagnosis. and religious/spiritual
Demographics/prognosis specific interventions
Incidence:
General Population: Medications Normally
Male: Prescribed for this
Female: Diagnosis:
Other:

Etiology
Genetic:

Biochemical:
(For Clinical Circle Patient
Medications)

Psychosocial:
Do any of these meds
need blood levels drawn?

Personality Factors/Other:

Lab/Diagnostics Routinely
Ordered To Monitor
Adverse Effects of
(For clinical Highlight or Medication?
circle your patient’s
symptoms that were
present upon admission
and dialogue whether they
are present now.)
PSYCHIATRIC DIAGNOSIS (Axis I, Axis II)

THIS PAGE IS the TEXTBOOK PICTURE of the selected DSM-IV Diagnosis

COMPLETE FOR ADMITTING PROBLEM (harm to self or others) page 2a (if needed)
PATHOPHYSIOLOGY DSM-IV TR Management/Treatment Nursing Diagnoses with Nursing Interventions
ETIOLOGY Diagnostic Criteria Pharmacology/Therapy Selected Outcomes
*Include risk factors Management Commonly This is textbook picture of Include cultural/ethnic/race
Any cultural/ethnic factors Prescribed for Diagnosis your diagnosis.. and religious/spiritual
Demographics/prognosis specific interventions
Incidence:
General Population: Medications Normally
Male: Prescribed for this
Female: Diagnosis:
Other:

Etiology
Genetic:

Biochemical:
(For Clinical Circle Patient
Medications)

Psychosocial:
Do any of these meds
need blood levels drawn?

Personality Factors/Other:

Lab/Diagnostics Routinely
Ordered To Monitor
Adverse Effects of
(For clinical Highlight or Medication?
circle your patient’s
symptoms that were
present upon admission
and dialogue if they are
present now.)
 PSYCHIATRIC MEDS PAGE 3
MEDICATIONS
Order of meds listed:
1) PO 2) SQ/IM 3) IV 4) PRN’s
Complete for all psychiatric meds prescribed (include prn’s):
1. Medication 1. Physician’s Orders COMMON Adverse SERIOUS Adverse Effects Nursing Interventions
2. Classification 2. Dosage ranges (child, Effects (Symptoms to report to (include incompatibilities)
3 Mode of Action adult, geriatric/IM/IV/SQ) (Very important for patient provider. Symptoms may on IV/IM/SQ include dilution
4. Pregnancy Safety Category 3. Why is patient taking this education and teaching) be life-threatening or lead amount, site selection, rate of
medication? administration
to serious complications.

1. Medication
2. Classification
3 Mode of Action
4. Pregnancy Safety Category
1. Physician’s Orders
2. Dosage ranges (child,
adult, geriatric/IM/IV/SQ)
3. Why is patient taking this
medication?
COMMON Adverse SERIOUS Adverse Effects
Effects (Symptoms to report to
(Very important for patient provider. Symptoms may
education and teaching) be life-threatening or lead
to serious complications.
Nursing Interventions
(include incompatibilities)
on IV/IM/SQ include dilution
amount, site selection, rate of
administration
 PSYCHIATRIC MEDS PAGE 4

MEDICATIONS
Order of meds listed:
PO 2) SQ/IM 3) IV 4) PRN’s
Complete for all psychiatric meds prescribed (include prn’s):
1. Medication 1. Physician’s Orders COMMON Adverse SERIOUS Adverse Effects Nursing Interventions
2. Classification 2. Dosage ranges (child, Effects (Symptoms to report to (include incompatibilities)
3 Mode of Action adult, geriatric/IM/IV/SQ) (Very important for patient provider. Symptoms may on IV/IM/SQ include dilution
4. Pregnancy Safety Category 3. Why is patient taking this education and teaching) be life-threatening or lead amount, site selection, rate of
medication? administration
to serious complications.

1. Medication
2. Classification
3 Mode of Action
4. Pregnancy Safety Category
1. Physician’s Orders
2. Dosage ranges (child,
adult, geriatric/IM/IV/SQ)
3. Why is patient taking this
medication?
COMMON Adverse SERIOUS Adverse Effects
Effects (Symptoms to report to
(Very important for patient provider. Symptoms may
education and teaching) be life-threatening or lead
to serious complications.
Nursing Interventions
(include incompatibilities)
on IV/IM/SQ include dilution
amount, site selection, rate of
administration
 PAGE 5

NON PSYCHIATRIC MEDICATIONS NON PSYCHIATRIC MEDICATIONS

List only major medications (no more than 10)

MEDICATION MD ORDER REASON HOME Any psych S/S this Any contraindications
(classification) PT TAKING MED med may cause? with psych d/o or med?
1 Yes/No

2 Yes/No

3 Yes/No

4 Yes/No

5 Yes/No

6 Yes/No

7 Yes/No

8 Yes/No

9 Yes/No

10 Yes/No

LABORATORY PAGE 6
AND DIAGNOSTIC
DATA
 ADX, Blood Alcohol, Liver Profile, Chemistry, CBC, HIV, Thyroid Profile, Hepatitis Panel, Urinalysis, etc.
(Circle laboratory work performed.) CHECK PHYSICIAN’S ORDERS!

List Abnormals ONLY VALUE = High (↑) Normal (WNL) Low (↓)
Test Lab Manual Normal Ranges VALUE/Date Interpretation of Tests R/T Diagnosis and Medications
Admit Most Recent

DIAGNOSTIC TEST Date Conducted ASSESSMENT

Interpretation
FORM of Tests r/t Diagnosis and Medications
Name of Test

PAGE 7
 *Mental Status Assessment Admitting Assessment Your Findings Day of Care
GENERAL: Include physical appearance, presence,
stated age vs. apparent age, proportion of both limbs to
trunk, body and breath odors, hygiene, eye contact, hair
color and appearance, distinguishing marks
MOTOR ACTIVITY: tremors, tics, mannerisms,
gestures, rigidity, hyperactivity, restlessness or
agitation, aggressiveness, gait pattern, echopraxia,
psychomotor retardation, range of motion
SPEECH PATTERNS: slow or rapid, pressured,
tone, volume, aphasia, speech impediment
GENERAL ATTITUDE: cooperative or
uncooperative, friendly, hostile, defensive,
uninterested, apathetic, attentive, interested,
guarded, suspicious
EMOTIONS (MOOD): sad, depressed,
despairing, irritable, anxious, elated, euphoric,
fearful, guilty, labile (ASK PATIENT)
AFFECT: congruent with mood, constricted,
blunted, flat, appropriate or inappropriate
THOUGHT PROCESSES: flight of ideas,
looseness of associations, circumstantiality,
tangentiality, neologisms, concrete thinking, clang
associations, word salad, perseveration, echolalia,
mutism, poverty of speech, concentration ability,
attention span
CONTENT OF THOUGHT: Delusions
(persecutory, grandiose, reference, control or influence,
somatic, nihilistic), suicidal or homicidal ideations,
obsessions, paranoia, suspiciousness, magical
thinking, religiosity, phobias, poverty of content (vague,
meaningless)
PERCEPTUAL DISTURBANCES:
Hallucinations (auditory, visual, tactile, olfactory,
gustatory), illusions, depersonalization, derealization
SENSORIUM AND COGNITIVE ABILITY:
Level of alertness /consciousness, Orientation (time,
place, person, situation), Memory (recent, remote,
confabulation), Abstract, Concrete
IMPULSE CONTROL: Ability to control
aggression, hostility, fear, guilt, affection, sexual
impulses/feelings
JUDGEMENT: ability to solve problems or make
decisions
INSIGHT: awareness of limitations, consequences
of actions, illness
*Townsend (2005), Psychiatric/Mental Health Nursing (5th Ed), Appendix B, pages 916-917

PAGE 8
SYSTEM ASSESSMENT CRITERIA Findings from chart Subjective from patient interview or
Your observation
ENT:
SKIN:
Wounds/incisional sites/dressings/drains
CHEST:
CARDIOVASCULAR

MUSCULOSKELETAL:
GASTROINTESTIONAL:

ENDOCRINE:
Blood Sugar Patterns: ac & HS, bid ac
GENITOURINARY:
GENITOREPRODUCTIVE:

OTHER:
PAIN: Location, radiation, quality, intensity, characteristics of
pain, aggravating factors, alleviation factors
RISK ASSESSMENT: Precautions: falls, seizure,
restraints, confusion
SAFETY: side rails up/down, call light in reach, armband,
allergy band, fall band, bed alarm on/off
NUTRITIONAL: Include height/weight (IBM/BMI,
changes) diet and caloric intake (adequacy), risk factors
malnutrition, hydration status
PSYCHOSOCIAL: Include impact of illness on self-
perception, coping strategies, social support, financial resources,
substance use history (Use Maslow’s Hierarchy of Needs)
DEVELOPMENTAL: Include impact of illness on role
performance and ability to achieve expected developmental status.
(use Erikson’s developmental stages) Immunization status
VALUES AND BELIEFS: Include cultural and
religious values/beliefs that affect health practices and client’s
expression of current spiritual needs. Chaplain/minister needed?
PATIENT/FAMILY TEACHING PLAN: Include
assessment of patient/family teaching needs, goals of teaching plan,
strategies, and evaluation of plan
DISCHARGE PLANNING: Discharge destination,
anticipated problems, available resources, referrals needed.
FACTORS hindering care: transportation, finances, housing,
disabilities (physical or mental), lack of support

Come to clinical with prepared questions (both assessment and therapeutic interactions) PAGE 9
PROCESS RECORDING
 *minimum of six (6) interactions

STUDENT NURSE COMMUNICATION PATIENT How could interaction have

VERVAL AND NONVERBAL TECHNIQUE VERBAL AND NONVERBAL Been reworded or rephrased?
Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:

Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:

Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:

Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:

PAGE 10
PROCESS RECORDING
 *minimum of six (6) interactions

STUDENT NURSE COMMUNICATION PATIENT How could interaction have

VERVAL AND NONVERBAL TECHNIQUE VERBAL AND NONVERBAL Been reworded or rephrased?
Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:

Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:

Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Critique your interaction:

Type of Technique Used:

Nonverbal: Nonverbal:
NSG DX:
Verbal (Quotes): Therapeutic/Nontherapeutic(circle) Verbal (Quotes):
PT outcome: PT will Critique your interaction:

Type of Technique Used: **Related findings:

Nursing Interventions:
Nonverbal: Nonverbal:

PAGE 11

Evaluation:
No.° NURSING DIAGNOSIS
1
2 Select three (3) nursing
3 diagnoses to expand!
4
5
6
7
8
9
10 Hospital Day #
SETTING PRIORITIES:
Remember MASLOW: Physiological before Psychological SUMMARY OF PATIENT DATA This page is a complete picture
Remember ABC’s: Airway before breathing, circulation of your patient on the date of care.
Remember Patient Safety: First of all Do No Harm (*Are there any barriers to providing
PREVENT Death and Disability care (religious, ethical, educational,
RELIEVE Suffering financial, age, gender, other?)
Remember GAF Remember Patient Priorities

NSG DX: NSG DX:

PT outcome: PT will x PT outcome: PT will

Related findings: Related findings:

Nursing Interventions: Belonging Nursing Interventions:

SAFETY

Clothing, food, shelter

Evaluation: Evaluation: