Mental Health Case: Li Na Chen, Part 1 Documentation Assignments

Mental Health Case: Li Na Chen, Part 1 Documentation Assignments 1. Document the search of Mrs. Chen and her belongings on admission. 2. Document the safety checks for Day 1. 3. Document the findings of the mental status examination of Mrs. Chen on admission. 4. Document the findings of the suicide assessment of Mrs. Chen. 5. Identify and document key nursing diagnoses for Mrs. Chen. 6. Referring to your feedback log, document all nursing care provided and Mrs. Chen’s response to this care. 7 harm anybody else? The patient said: No. 12:0 3 You asked the patient: Have you ever tried to harm or kill somebody else? 12:2 0 The patient said: I don't think I can go on.nYou answered: Are you thinking about hurting yourself? nYou used the therapeutic technique of restating. 12:2 5 You asked the patient: Can you tell me what a desired outcome of treatment would be for you? The patient said: I don't know. I can't do anything right. 12:3 8 You supported the patient's husband. 12:5 4 You asked the patient: How do you understand your problems? 13:0 7 The patient said: I'm nothing.nYou answered: Do you feel that you have no self-worth? nYou used the therapeutic technique of translating into feelings. 13:1 1 You asked the patient: Do you ever see or hear things that other people do not? The patient said: No, I do not. 13:1 8 You asked the patient: Do you find that you worry more than others? The patient said: I worry about many things. 13:2 6 You asked the patient: Are you frightened of anything? 13:3 6 The patient said: No one will care about me anymore.nYou answered: Who do you care about? nYou used the therapeutic technique of exploring. 14:3 You removed potentially dangerous objects. 7. Document patient education regarding medications. 8. Document your handoff report in the SBAR format to communicate the care plan for Mrs. Chen to the nurse on the next shift.