Patient Information:
- Patient Name: John Smith, ID: 1234567, Date of Birth: 01/01/1980
- Date and Time of the Nursing Assessment: 01 November 2024, 10:00 AM
- Location: Psychiatric Ward, Room 201
Subjective:
- Reason for visit/admission: Patient reports feeling increasingly anxious and experiencing panic attacks. States difficulty sleeping and loss of interest in activities.
- Patient’s description of history of present illness including previous diagnoses and treatments: Diagnosed with Generalized Anxiety Disorder and Major Depressive Disorder 2 years ago. Currently on Sertraline 100mg daily. Reports recent increase in anxiety symptoms despite medication.
- Patient’s description of previous psychiatric hospitalizations or intensive outpatient treatments: No previous hospitalizations. Attended an intensive outpatient program for 6 weeks last year.
- Patient’s description of medical history and past surgeries: No significant medical history. No past surgeries.
- Patient’s description of mood: Reports feeling sad and anxious.
- Patient’s description of sleep: Difficulty falling asleep and staying asleep. Wakes up frequently during the night.
- Patient’s description of suicidal or homicidal ideation and future thinking status: Denies suicidal or homicidal ideation. Expresses hope for improvement with treatment.
Objective:
- Vitals: BP 130/80, HR 88, RR 16, Temperature 37.0°C, Oxygen Saturation 98%
- Physical assessment findings: Appears anxious and restless. No acute distress. Skin is warm and dry. Alert and oriented to person, place, and time.
Assessment:
- DSM V diagnosis or identified needs based on the subjective and objective data: Generalized Anxiety Disorder, Major Depressive Disorder.
- Prioritization of patient care needs: Address acute anxiety symptoms, improve sleep, and assess for medication adjustment.
Plan:
- Care plan adjustments or interventions planned for the shift: Administer PRN dose of Lorazepam 1mg for anxiety. Encourage patient to participate in group therapy. Monitor sleep patterns.
- Collaboration with other healthcare team members: Discuss patient's condition with the psychiatrist and social worker.
Interventions:
- Specific nursing interventions performed or initiated during the shift: Administered Lorazepam 1mg. Provided education on relaxation techniques. Encouraged patient to express feelings.
- Response to interventions: Patient reported a decrease in anxiety after Lorazepam administration. Participated in group therapy.
Evaluation:
- Evaluation of patient’s response to interventions and progress towards care goals: Anxiety symptoms improved. Patient is more engaged in activities.
- Any changes in patient status or findings: No significant changes in vital signs or physical assessment findings.
Plan for Continuing Care:
- Next steps in patient’s care plan: Continue current medication regimen. Schedule follow-up appointment with psychiatrist. Encourage continued participation in therapy.
Additional Notes:
- Any patient or family education provided, including discharge planning or instructions for home care: Provided education on medication side effects and importance of adherence. Discussed coping strategies for anxiety.
- Communication with patient and family about care decisions, concerns, and preferences: Discussed treatment plan and addressed patient's concerns about medication.
Patient Information:
- [Patient Name, ID, and Date of Birth (mention if available)]
- [Date and Time of the Nursing Assessment (mention if available)]
- [Location (e.g., department, room number) (mention if available)]
Subjective:
- [Reason for visit/admission, including patient’s verbalized concerns or symptoms (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of history of present illness including previous diagnoses and treatments (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of previous psychiatric hospitalizations or intensive outpatient treatments (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of medical history and past surgeries (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s family history of mental illness (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of mood (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of sleep (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of mania or hypomania (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of substance use (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of suicidal or homicidal ideation and future thinking status (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of childhood (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of attention and concentration (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of post traumatic stress disorder symptoms (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of neurodevelopmental and developmental screening (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s description of social communication issues, including social reciprocity, non verbal communication, and maintaining relationships (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any expressed concerns about treatment, care, or the healthcare environment (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient’s and family’s understanding of the diagnosis, treatment plan, and care needs (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Objective:
- [Vitals including BP, HR, RR, Temperature, Oxygen Saturation, etc (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Physical assessment findings, including general appearance, skin integrity, presence of edema, heart and lung sounds, abdominal assessment, mobility status, and any other relevant clinical signs (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Results of any bedside tests or monitoring (e.g., blood glucose levels, INR for patients on anticoagulants) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Review of medical chart for recent lab results, diagnostic tests, orders, and medication changes (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Assessment:
- [DSM V diagnosis or identified needs based on the subjective and objective data (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Prioritization of patient care needs (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Plan:
- [Care plan adjustments or interventions planned for the shift, including medication administration, wound care, mobility assistance, patient education, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Scheduled procedures or tests for the day (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Interventions:
- [Specific nursing interventions performed or initiated during the shift, including administration of medications, treatments, patient education provided, coordination of care, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Response to interventions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Evaluation:
- [Evaluation of patient’s response to interventions and progress towards care goals (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any changes in patient status or findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Plan for Continuing Care:
- [Next steps in patient’s care plan, including any planned adjustments to interventions, additional tests or procedures, follow-up needs, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Additional Notes: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any patient or family education provided, including discharge planning or instructions for home care (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Communication with patient and family about care decisions, concerns, and preferences (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any safety concerns or incidents reported (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
