Can someone tell me if CNS charting with the new codes is identical to the PMHNP charting recommendations?
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My facility is trying to decide if the BIRPE format is the best, most user friendly way to chart. What are other facilities using?
Currently we are charting a head to toe physical assessment twice a day, a mental status nursing note twice a day, plus other charting like education, fall risk, IPOC, delirium assessment, pain assessment, braden, and on the early warning system (EWSS). All this charting takes nursing's time away from the bedside with patients. I am wanting to decrease the amount of charting nursing is required to do. For those of you that work on units similar to mine, how often are you charting on the patients and what are you chartings?
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We are looking at moving this to computerized charting. Reaching out to see who has safety checks computerized, what types of technology​ you use to easily get the safety checks done (i.e. scanning name bands with zebra phone) and if you document what the patient is doing at the time the safety check is being done (i.e. sitting in room, visiting with peers etc.)
4 Comments - I'm not sure if other EHRs provide a unit-level documentation option (ie: chart all checks without having to open and close multiple patient charts) - such an option would have been welcome at the time. For the time being, we are proceeding to document observations on paper - but the patient label is applied to their rounding sheet and is scanned into the EHR by clerical staff (so it ultimately is retained in their chart). While I would prefer an electronic option, Epic simply didn't offer a feasible solution back in 2018
I am currently on the search for a new collaborating psychiatrist willing to be available for questions, challenging client situations, and for 2-3 x a year chart reviews. I am currently located in Perry county but my work generally is in the Columbus region
If the route is through the nursing station or charting area or offices, and the patient is NOT in restraints while being escorted, then there is the chance that the patient might break free and access items that could be used to harm (self or others)