Subjective: A direct quote from the patient should be written in the chart. Information reported by the patient may include complaints, symptoms, side effects, life events, and feelings. Objective:
Discuss pertinent clinical events and observations of the nursing staff.
Affect: Flat, blunted, labile, full.
Mood: Dysphoric, euphoric, angry, euthymic, anxious.
Thought Processes: Quality and quantity of speech. Tone, associations and fluency of speech and speech abnormalities.
Thought Content: Hallucinations, paranoid ideation, suicidal ideation.
Cognitive: Orientation, attention, concentration.
Insight: Ability of the patient understand his current problems
Judgment: Decision-making ability.
Labs: New test results.
Current medications: List medications and dosages. Assessment: This section should be organized by problem. A separate assessment should be written for each problem (eg, stable or actively psychotic). Documentation of dangerousness to self or others should be addressed.
The assessment should include reasons that support the patient's continuing need for hospitalization. Documentation may include suicidality, homicidality, informed consent issues, monitoring of medication side effects (eg, serum drug levels, WBCs, abnormal involuntary movements).
Plan: Include changes to current treatment, any future considerations, and issues that require continued monitoring should be discussed.
Example Inpatient Progress Note
5/10/00 Psychiatry R2
S : "The FBI is trying to kill me." The patient reports that she was unable to sleep last night because the FBI harassed her by talking to her. She became frightened during our interview and refused to talk after 5 minutes. O : The patient slept for only 2 hours last night and refused to take medications that were offered to her. Patient also is reluctant to eat or drink fearing that the food is poisoned. On exam, the patient displayed poor eye contact, and psychomotor agitation. Affect: Flat. Mood: Dysphoric.
Thought Processes: speech is limited to a few paranoid statements about the FBI. Otherwise the patient remains electively mute.
Thought Content: Auditory hallucinations and paranoid ideation. The patient denies visual hallucination, suicidal ideation. The patient denies homicidal ideation, but states that she would harm anyone from the FBI who tried to hurt her.
Cognitive: The patient would not answer these questions, due to paranoid ideation. Insight: Poor Judgment: Impaired A: 1. Schizophrenia, chronic, paranoid type with acute exacerbation. The patient is actively psychotic and paranoid, with extensive impact on functioning P: 1. The patient remains actively paranoid and intermittently compliant with recommended medication. Continue to encourage patient to take medication - Risperdal 2 mg PO BID.
2. Continue to monitor sleep and food and fluid intake. Draw electrolyte panel in the AM to monitor hydration status.
3. Legal Status: The patient is currently hospitalized on an involuntary basis. The patient meets criteria for involuntary hospitalization due to an inability to provide food clothing and shelter for herself.
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