nursing daily charting- p bworks（护理每日图表- p bworks）.docVIP

Nursing 214L Daily Charting Student: Date: Client History Name (initials only): Age: Gender: Unit: Current Legal Status (Vol, 5150, 5250, Conservatorship, T-Con): 5150 Advisement (quote): 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: Previous Hospitalization: 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 (plan and/or intent): Homicidal Ideation (plan and/or intent): 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, pr