Nursing Documentation in Psychiatry

This two-hour lecture/discussion provides an overview of documentation related to the use of the nursing process in inpatient psychiatric care. Content includes a review of the Resnick Neuropsychiatric Hospital charting policy/procedure as well as the use of S.O.A.P. format in evaluating the effectiveness of the Nursing Care Plan. Specific guidelines are given for documentation of errors, consents, unusual occurrences, suspected abuse, patient/ family teaching and discharge planning. This information is integrated into our Essentris On-Line Charting System.