Psychiatric Diagnosis(s): Chief Complaint (subjective, patient’s own words): Hyperactivity Admission Status: Voluntary or Involuntary History of Present Illness: Psychiatric History: Past :
Pathophysiology (In your own words): Risk Assessment: Does patient have thoughts of hurting themselves? Yes or No Does patient have thoughts of hurting others? Yes or No Suicide risk factors: Protective factors:
Complications/Potential Complications (Physiologic Adaptation(s)/Reduction of Risk Potential): **Include substance use/abuse history
Psychosocial Concerns (Psychosocial Integrity): **Include psychosocial history
Assessment (Physiological Adaptation) **performed by the student **include age/sex **MSE, MMSE, CIWA, COW, if applicable)
Labs and Diagnostics (Reduction of Risk Potential) ** Must include therapeutic drug levels, tox screen and pregnancy test.
Planning and Goals (short term and long term goals) **Actual priority problems with prioritized goals
Nursing Interventions (Basic Care and Comfort, Safety and Infection Control) **What did the student/nurse perform throughout the day **Include rationale
Evaluation of Interventions
Medication Name (Generic) and Drug class
Patient’s Dose, Route, and Frequency
Why is patient receiving this medication?
Nursing considerations (labs, assessment, etc.)
Side effects and Major adverse effects
Alternative Treatments with benefits and risk: For example, if patient is currently being treated with SSRI’s for depression what other options for treatment are available?
Patient Teaching (Health Promotion, Safety and Infection Control, and of Care):
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