Daily Nursing Note

Assessment & Plan Elements
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[text size="20"]: Patient [checkbox value="maintained safety throughout the shift|was active and appropriate in the milieu|accepted scheduled medications without difficulty|isolated from the milieu throughout the majority of the shift|refused treatment programming|was present in the milieu but displayed minimal participation in treatment programming|displayed minimal interactions with peers"][text size="20"]. Patient denied [checkbox value="suicidal ideation|homicidal ideation|auditory hallucinations|visual hallucinations|withdrawal concerns|adverse effects of medications"]. Patient presented as [checkbox value="Bright|Euthymic|Constricted|Blunted|Flat|Dysphoric|Anxious|Depressed|Sad|Tearful|Agitated|Irritable|Labile"]. [textarea cols="80" rows="8"] [checkbox value="Fall precautions maintained throughout the shift|CIWA protocol maintained throughout the shift|COWS protocol maintained throughout the shift|Contact precautions maintained throughout the shift"][textarea cols="20" rows="4"]. Plan to [checkbox value="Maintain fall precautions|Maintain CIWA protocol|Maintain COWS protocol|Maintain contact precautions|Continue encouraging patient to accept scheduled medication|Continue encouraging patient to participate in treatment programming|Continue to monitor patient for safety|Continue monitoring for improvement of psychotic symptoms|Transfer patient to inpatient unit upon bed availability"]. CCardurns, RN
: Patient . Patient denied . Patient presented as . . Plan to . CCardurns, RN
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