changes in the workplace

Working in a locked psychiatric hospital has many challenges but the one thing that has been challenging is patient documentation. When the electronic system was created to replace written charting, it seems as though they forgot to create a template to help nurses properly document on patients. There are some nurses who document in detail which in turn helps the treatment team (consisting of the therapist, MD, case manager, and RN) to develop specific individual care plans for patients. Then there are some nurses who do not document enough information and then treatment and care plan are delayed due to missing information. Examples of missing information consist of documenting triggers that cause patients to self-harm, reasons why patients are trying to elope, or documenting patient’s creating shanks out of plastic utensils and pencils to use towards peers, and many more.I would change how we document on patients’ charts due to information being missed. We deal with different levels of patients who struggle with depression, anxiety, bipolar, and many other mental health illnesses. Some cope with unhealthy coping skills by self-harming (using different objects on their bodies, punching objects, and more) to temporarily cope with their emotions. We have patients who process what they are experiencing in different ways, such as speaking to staff, pacing, writing in their journals, artwork, etc. We have many ways of helping each patient during all shifts to incorporate healthy coping skills to manage their many struggles.In my workplace, we’ve had a good amount of changes with seasoned nurses retiring, nurses transferring to a different unit, newer nurses in the psych field, and just newer graduates in general so training on documentation has declined. It would be nice to retrain seasoned nurses and newer nurses so that everyone is documenting in the same format. It would also be wonderful to have a template created so all the nurses, new and seasoned, can be guided on what to assess, what to discuss with the patient, and what to document on the patient’s chart. For a change in documentation to work properly, I believe it would be helpful for the treatment team to come together and decide what information is priority to know so that treatment plans are created for the individual patient. Since each patient have different needs, have different ways of coping, different medication requirements, and different individualized therapy, it is pertinent to document properly on each patient. The current way of documenting does not cover the SOAP method, meaning subjective, objective, assessment, and planning. Currently the documentation basically covers subjective and assessment only. By utilizing the SOAP method, the nurse would be able to tell the patient’s story through their eyes and know what they are feeling; be able to assess the patient’s behavior, body language, and appearance; assess patient’s situation and if they need to be on close observation; and then notify the treatment team of any changes.To introduce the SOAP method, a training could be scheduled to launch the new way of documenting. A printout could be provided for each nurse with all the key points when assessing each patient and documenting on the patient’s chart. Nurses could use computers in the training center and work with a fake patient to document on their chart so they can familiarize themselves with the new method. A template could be printed and laminated for the nurses to carry in their pocket as well until they familiarize themselves with the method. The treatment team would allow the nurses to have a certain amount of time (approx. 30-60 days) to trial the new way of documenting. Once this has been into play for a period, the treatment team can evaluate the process and determine how well the change is going or if it needs to be updated further. Unfortunately, there are some people who do not appreciate change and cannot see how certain changes will be beneficial in the future. Some people are stuck in wanting things to stay the same, however not realizing that working in the medical field there will always be change. As someone who adapts to change easily, I would assist nurses realize that this change would be for their best interest in the long run. Treatment teams could assign staff members to assist as a super user on the unit during different shifts and answer any questions or concerns nurses may have. These super users could even be nurse’s advocates with any other changes they may feel is needed to be incorporated. It may take some time for some nurses to grasp the new way of documenting, however it would benefit the patients.

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