Focused Exam Schizophrenia:Nursing Admitting Note

1/4/2020 Focused Exam: Schizophrenia | In Progress Attempt | Shadow Health https://app.shadowhealth.com/assignment_attempts/5886664 1/3 Focused Exam: Schizophrenia (Part 2 of 2) Therapeutic Intervention III - Winter 2020, NUR 304 R eturn to Ass ignment (/assignments/288273/) Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor i nsight into your learning proces This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p Documentation Review N ursin g Admitting... M ental Status Note S BAR Nursing Admitting Note Student Response Model Documentation Chief Complaint Voices telling patient that his life is ending soon. Eric Ford is a 28 -year-old African American man who wa brought to the ER by his mother for acute auditory hallucinations and paranoia. History of Present Illness Schizophrenia diagnosed at age 23. 4 total hospitalizations related to schizophrenia Eric Ford has a history of chronic paranoid schizophrenia onset age 23. Three previous hospitalizations with the m recent 2 years ago. History significant for a suicide attem overdose at age 25, requiring ICU admission. Patient has been sleeping or eating well. His mother reports that he r out of medication 9 days ago and is concerned for his saf He denies suicidal intent and states that he sometimes lis to music to avoid paying attention to the voices. Denies homicidal ideation. Does not initiate conversa tion. Presen + auditory command hallucinations. Appears to be limited ability to complete activities of daily living, disheveled wit soiled clothing. Allergies No known allergies NKA / NKDA Past Medical Histo ry No known health conditions besides schizophrenia (diagnosed at 23 y/o) 3 previous hospitalizations because of schizophrenia at ages 23, 25, 26. Schizophrenia, since age 23