Standards of care in documentation of psychiatric nursing care

Small nonteaching hospitals with psychiatric units often encounter problems meeting regulatory agency requirements for documentation and patient care. The CNS identifies and updates clinical policies and procedures to correct actual or potential deficiencies in nursing practice. Use of standards of care necessitates charting systems that streamline documentation and avoid unnecessary duplication. Unlike medical-surgical units, where the standard of care includes nursing interventions based on a particular patient problem, psychiatric problems are often complex due to individual variables not specific to a diagnostic category. A clinical application is described that utilizes a psychiatric nursing database admission interview and problem-intervention-evaluation charting format to unify the treatment care plan with progress notes.