Oh oy cul of SoftNURS 110 Long-Note Documentation Guide Intervention, Response (Evaluation) format Utilize the Assessment, ‘Assessment: mnt doing and where is time spent (isolating in day area or social with peers in day area, or seclusive ‘What is the pati senshi)? What isthe affect and mood? Oriented? What are the symptoms (provide examples/descriptions of any fatlveinations or delusion, include a quote whenever possible)? Ifany hallucinations are present, must assess for pernmand hallucinations. Is the patient suicidal or homicidal? Did the patient attend group and did he or she participate? I suicidal ideatios ae preset, must do a fll suicide assessment. f the patient denies symptoms, but they appear to be present, describe behaviors such as appears to be responding to interel stimuli by tilting head and listening and laughing in response to unheard voice), How is the patient’s thought process (logical, illogical, racing thoughts, jumping topics)? How is the patients insight? Example: A-Patient in day area much of shift socializing with peers. Patient remains depressed but states, “am feeling less hopeless today.” Affect remains flat, but does brighten on approach. Pt. remains alert and oriented x3, Pt remains free from hallucinations and delusions, but does admit to suicidal ideations. Pt states no plan at this time but states, “I just want to goto sleep and not wake up at night. I feel more hopeless at night.” Pt attends all groups during the day and participates regularly. Pts thoughts remain logical but pt continues to report decreased ability to focus and maintain atention. Pt has good insight into depression Intervention: ‘What are you and your patient's goals for the day? How does the patient plan to achieve them? What did you discuss during your 1:1? Ifpatient is suicidal, indicate that a no harm contract was completed verbally with the patient. ‘What have you encouraged the patient to focus on? What education did you provide? This is where you acknowledge what you did for your patient and whet your patient is doing for him or herself. (Provide distraction, ‘discuss positive coping skills, educate on illness, use distraction techniques, provide reality orientation) Example: I- Pt set goal of keeping activing in the evening before bed and listing 5 reasons for wanting to ive. Pt plans to walk unit before evening group and write in journal before bed. Pt did contract for safety and verbalized plan to talk to stafF if suicidal ideations or feelings of hopelessness escalate before bed Encouraged pt to continue to attend groups and socialize with peers. Educated on side effects of new medication, venlafaxine XR and patient verbalized understanding. Offered to tum music on in pt room before bed. Response or Evaluation: “This is the patients response tothe interventions. Did they goto group interact with peers, maintain safety, remain cooperative with staff? Example: R-(E)- Pt remains social with peers and has attended all groups with good participation today. Safety has been maintained, Pt has listed 3 reasons to ive and is continuing to work om list. Pt will request his room before bed.> cro Dorie eh xU LUD. TrerRectine coping § Eepaired, Hood Pequlasion LBUdert goat’, PA wsiiy compete cutpaker ECT +recimerts. Pakiewt Qoals Complete. treatments, Pinisin school) eter med enmaggrott a ining S ECT © By ond of Srit+ © By On dt ne Week A By discnarge () By end ot Mnve+Monroe County Community College ‘Nursing 110 Rubric for Grading Concept Maps Date 1 / d/o) Name GD insat No_NA ender, age, dle, race, et ude 3. All pertinent abs including why they were done and interpretation nduded. — 4. One priority nursing problem included, us $: One goal and atleast 3 outcomes fr each nursing problem included thats realnic and meamurable, C4 6. At least 4 nursing interventions included total with rationales and documentation ZB [7- All psychotropic medications and why patient is taking them included. 8. Evaluation of nursing outcomes included. 2 2. Patient stents and areas for improvement includ | home status, adherence, religion, finances, et) Z 10. Home care and discharge needs included (ed needs, et) 2 [1.2. Relationships of nursing process and n of pan of care able to be explained. [Student Comments: [Clinical instructor Comments: were