Psych Intake Template

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.