Need to create an app for a psychiatric progress note that has drop down menus and fill in the blank for a nurse and possible a paraprofessional and other disciplines. NURSE is the main focus for now.
I would like this app to consist of a note with 4 paragraphs that consist of
Nurse met Consumer in his her home in the community. Consumer's gait was unsteady. Consumer was alert and oriented to time, place, president, person and situation. Consumer's rate of speech was with in normal limits. Consumer was dressed inappropriately. Consumer's hygiene was wnl poor fair. Consumer's affect was calm anxious energetic. Consumer reports mood as, "Good." Consumer denies all other s/s of his her mh diagnosis. Consumer denies suicidal or homicidal ideations. Consumer denies SI/HI.
Nurse assessed consumer for medication compliance, efficacy and side effects. Nurse assessed for s/s of his her mental health diagnosis. Nurse assessed for SI/HI. Nurse assessed for suicidal/ homicidal ideation. Nurse educated consumer on the importance of medication compliance. Nurse attempted vital signs. Nurse encouraged consumer to use coping skills such as journal writing, walk/exercise, and listening to music. Nurse engaged in active listening and empathic response while developing a rapport with the consumer to create a comfortable environment to express all concerns. Nurse encouraged tobacco cessation. Nurse encouraged sobriety.
VS: BP 176/90, P 97, RR 18, T 98.3, HT 5ft, 6in WT 144lbs Consumer reports to be medication compliant. Consumer reports to be medication noncompliant. Consumer reports to have no complaint of medication side effects. Consumer reports medications are not effective. Consumer was not receptive to medication education and has some difficulty understanding his her disease process and associated symptoms. Consumer reports to cope with mental health symptoms by journal writing, walk/exercise, and listening to music with positive effects. Consumer reports sleeping habits are with in normal limits. are sporadic have decreased increased. Consumer is eating (2-3) meals daily and is drinking (4) glasses of water daily. Consumer reports last BM this AM. Consumer is not maintaining sobriety. Consumer is smoking (1-5) cigarettes daily with no interest in smoking cessation. Consumer was receptive to Nurse visit today AEB consumer meeting with nurse today.
Continual education is necessary on additional coping skills, medication compliance, and importance to attending treatment sessions, weekly groups and scheduled psychiatrist appointments.
Consumer to f/u with ACT team.