Nursing Follow Up Note
Precision Psychiatric Services
Patient Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Nurse:
Please Select
Carolina Ruiz
Amy Monger
Mary Coffia
Rochelle Horn
Jacqueline Espino
Elizabeth Aparicio
Alexis Alender
Kendra Cavasos
Subjective:
"I'm good"
"I'm fine"
"I'm ok""
"The medications are working"
"I need a higher dose"
"I need a lower dose"
"I don't want medications"
"I am anxious"
"I am depressed"
"I would like medications"
"I would like to see a Psychiatrist"
"I would like to see a therapist"
Denies any medication side effects
Objective
AAOx3
Denies SI/HI
Denies hallucinations
Admits to hallucinations
Cell is clean and organized
Disheveled
Agreed to seek out staff for safety
Disorganized speech
Assessment:
Situational anxiety and depression related to current charges
Not an imminent danger to self or others
Experiencing hallucinations
Improving
Knowledge deficit
Plan
Continue current treatment
Follow up as needed
1 week follow up
2 week follow up
1 month follow up
Refer to Psychiatrist
Refer to Therapist
Education
Educated on the importance of medication compliance
Education on the sick call process
Advised to seek out staff for safety
Verbalized understanding
Nurse Signature
Date of Evaluation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: