Psychiatry
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DAP SHIFT [checkbox name="A" value="0700-1930|1500-2330| Transfer note"]

D-[text name="variable_1" default="NAME"] is XXX year old [checkbox name="A" value="male|female"]. Diagnosed with [checkbox value="MDD|SChizophrenia|unspecified schizophrenia spectrum and other psychotic d/o|substance abuse|bipolar d/o|impulsivity|mood lability|adjustment d/o|schizoffective d/o|depression| other psychotic d/o"] [textarea memo="other" default="" rows="1"]
[textarea memo="*QUOTES* *REQUIRED*" default="" rows="8"]


[conditional field="A" condition="(A).is('Followup')"][comment memo="Indicate whether diagnosis changed, reason for change, date and time of change
"][/conditional][checkbox value="
Major depressive disorder|recurrent|single episode|mild|moderate|severe|
Generalized anxiety disorder|
PTSD|acute|chronic|
Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"]
[textarea rows="5"]


[checkbox value="Low risk of anger and aggression |Moderate risk of anger and aggression|High risk of anger and aggression|Q30|Q15|Q5|1:1| level of observation for safety"]

0700- Received report for[text name="variable_1" default="NAME"]. NO apparent distress.

0800
[checkbox value="Ate 100% breakfast|Refused Breakfast|Denies SI|HI|Hallucinations|reports SI, no plan|reports SI with plan ----|AH non-command|CAH| treatment team aware"] [textarea memo="other" default="" rows="1"]
[textarea memo="*QUOTES* *REQUIRED*" default="" rows="8"]



1700

[checkbox value="at the dayroom|In room|NO apparent distress|NO self harm this shift.|NO aggression.|transfer to G3 unit|transfer to E2|escorted by MHT. Transferred with Chart, EMAR consent, Kardex and personal belongings."]



A- [text name="variable_1" default="NAME"]has been
[checkbox value="Calm,|cooperative|polite|pleasant upon approach|visible|isolative|keep to self|interactive|minimal interaction|poor boundaries|needs and follows redirection|uncooperative|poor impulse|labile|aggressive|verbally abusive to staff| prefers male/ female staff| manipulative"]



*Interval History*

Patient appears [select value="stated age|older than stated age|younger than stated age"]
Patient presents with [comment memo="SYMPTOM"][checkbox value="good|fair|poor|grooming |and hygiene|showered today|malodorous|disheveled|unkempt|matted hair|steady gait| unsteady gait|speech clear| tangential| disorganized| flight of ideas| coherent| delusional| depressed| bright affect| "] [textarea memo="other" default="" rows="1"]



Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"].
Affect- [checkbox value="sad|tearful|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"].

Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"] [textarea memo="other" default="" rows="1"]
It seems to [checkbox value="be very brief in duration|last for awhile then goes away|always be present"]
The patient notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"]

[checkbox name="Speech" value="" memo="speech"][conditional field="speech" condition="(speech).is('')"]
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][textarea memo="other" default="" rows="1"].
[checkbox name="Thought" value="" memo="thought process"][conditional field="thought" condition="(thought).is('')"]

Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"].
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"].
Thought Content: [select value="no evidence of delusions, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"].
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"].
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on patient's answers to interview questions|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |unable to assess due to cognitive impairment|"][checkbox value="able to name objects|able to repeat phrases"] [textarea memo="other" default="" rows="1"]
Judgment and Insight:
Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"].
Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]








[checkbox value="He denies recent or current ever or chills (100.4 F or greater), cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea and agreed to report to staff any of this symptoms.|

He/she was provided education and verbalized understanding of keeping social distance, proper handwashing and wearing face covering.|


Provided nursing care with respect and preserved the dignity of the individual. Encouraged personal hygiene and medication compliance was reinforced. Miller was provided education on the importance of handwashing in infection control and was able to verbalize the importance of handwashing|



Patient is monitored as a seizure fall risk per hospital protocol, due to history of seizure. His personal belongings are within reach at his bed side. He wears non-skid footwear. Fall sign noted on door. Fall risk has been indicated on SBAR along with the monitor board (with fall sticker). Seizure/ fall risk education given, he verbalized understanding. No seizure or fall activity noted during this shift. Fall risk education provided upon admission. and environmental rounds done to ensure bedroom was free from clutter and pathways to exit was clear for safe ambulation. Fall risk assessment is every 10-days|
Provided nursing care with respect and preserved the dignity of the individual. Environmental rounds completed to ensure safe and clutter free environment.|
Legal status verified, Medications, shift movement log and unit census board updated. Kardex and med Consents placed in chart, property and valuables secured from storage. "]

Significant Medical Issues:
[textarea rows="5"]

ASSESSMENT
[checkbox name="prognosis" value="" memo="Prognosis statement"][conditional field="prognosis" condition="(prognosis).is('')"]Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]. [/conditional][conditional field="prognosis" condition="(prognosis).is('')"]Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to|is not currently willing to engage in recommended|has chronically had poor response to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox name="barrier" value="Barriers to success include: "][/conditional][conditional field="barrier" condition="(barrier).is('Barriers to success include: ')"][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"].[/conditional] [conditional field="prognosis" condition="(prognosis).is('')"][checkbox name="strength" value="Patient strength for success include: "][/conditional][conditional field="strength" condition="(strength).is('Patient strength for success include: ')"][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment"][textarea memo="strengths" rows="1"].[/conditional] [textarea rows="5"]

PLANS




P-Continue
[checkbox name value="Q30|Q15|Q5|1:1|
observation order per MD for safety. |Continue treatment plan as ordered. Monitor for changes in behavior and evaluate the effectiveness of medications, observe for adverse/side effects of medications. Will provide daily interactions and review goals of the treatment plan with patient.| Reinforce patient education on s/s of COVID 19, proper handwashing, social distancing and face covering. Provide safe and therapeutic environment.

Diabetic-/ HTN
Continue monitoring Donna's vital signs. Continue administered medical medications, monitor any signs and symptoms of hyper/hypoglycemia.|

HYPERTENSION---|



Provide nursing care with respect and uphold the dignity of the individual.|
Endorsed to E2 RN for continuity of care.|
Endorsed to G3 RN for continuity of care.|
Endorsed to incoming nurse for continuity of care.|
Xennia Urbano, PNII "]



[checkbox name="Depression" value="-Patient will report score on PHQ-9 of "][conditional field="Depression" condition="(Depression).is('-Patient will report score on PHQ-9 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Anxiety" value="
-Patient will report score on GAD-7 of "] [conditional field="Anxiety" condition="(Anxiety).is('
-Patient will report score on GAD-7 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Nicotine" value="
-Patient will reduce nicotine intake by 50% within "][conditional field="Nicotine" condition="(Nicotine).is('
-Patient will reduce nicotine intake by 50% within ')"][select value="1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Sleep" value="
-Patient will experience 6+ hours of uninterrupted sleep per night within "][conditional field="Sleep" condition="(Sleep).is('
-Patient will experience 6+ hours of uninterrupted sleep per night within ')"][select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Cognition" value="
-Patient will report impact of cognitive impairment as mild/resolved within "][conditional field="Cognition" condition="(Cognition).is('
-Patient will report impact of cognitive impairment as mild/resolved within ')"][select default="3" value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"]
DAP SHIFT

D- is XXX year old . Diagnosed with other
*QUOTES* *REQUIRED*








0700- Received report for. NO apparent distress.

0800
other
*QUOTES* *REQUIRED*



1700





A- has been




*Interval History*

Patient appears
Patient presents with SYMPTOM other



Mood- other.
Affect- other.

Which is described asSEVERITY other
It seems to
The patient notices that it is sometimes improved by Modifying factors

speech

PLANS




P-Continue




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