Nursing Daily Charting

Daily Charting 1

Nursing Daily Charting

Student: Date:

Client History

Name (initials only):Age:Gender:

Legal Status (Vol, 5150, 5250, Conservatorship, T-Con):

Date of Admission:

Psychiatric Diagnosis (Axis I):

Personality Disorder / Mental Retardation (Axis II):

Medical and (or) physical problems (Axis III):

Psychosocial and Environmental Problems (Axis IV):

(problems with primary support group, education, occupational, housing, economic, access to heath care)

Global Assessment of Functioning (Axis V):

Presenting Problem

Reason for hospitalization (Client’s own words):

Current stressors:

Mental Status Examination

Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy make up):

Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other):

Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent):

Affect (blunted, flat, guarded, labile, expansive, sad, other):

Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, other):

Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, other):

Thought Content:

Suicide Ideation:

Homicidal Ideation:

Hallucinations (auditory, visual, olfactory, gustatory, tactile):

Delusions ( bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania):

Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other):

Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other):

Cognition (orientation, memory recall, concentration, attention span):

Insight:Judgment:

Coordination/gait/notable movement:

Cultural issues, familial concerns and religious affiliation that may affect his/her care:

Current Physical Health (Axis III)

Vital Signs -T:P:R:BP:

Pain (Numeric 1-10):Location: Character:

How would you describe your health: Excellent Average Good Poor

Nutritional Status: Diet:Feeding supplement:Swallowing / Chewing difficulty:

Elimination Pattern:

Activity-Exercise Pattern:

Sleep-Rest Pattern:

Substance Abuse:

Signs of withdrawal symptoms:

Addictions:

Teaching assessment:

Discharge Plans:

Additional data:

Based on the nursing assessment you have just completed, Identify subjective and objective data and list all nursing problems including cultural issues and teaching needs (Prioritize Problems):

1.

2.

3.

4.

Interventions:

Evaluation (patient response to interventions):

: MEDICATION LIST

Medication

Medication