Templates

Treatment Summary

Upon assessment and observation, patient does not currently display behaviors, voice intent, or manifest signs indicative of being a danger to themselves, being a danger to others or intent to elope at this time. Safety precautions remain in place. Scheduled reassessments, in line with protocol, conducted to ascertain patient’s mental and emotional status.

Admission Note:

Patient admitted to unit and admission assessment performed.

Patient shown unit facilities, briefed on rules, procedures, and routines. Patient verbalized understanding after all questions were answered. Patient remained cooperative during admission. Patient to follow care plan with regular assessments. Team collaboration in place for comprehensive care.

Teaching Topics

Sleep Hygiene

Discussed the importance of establishing a regular sleep-wake cycle, reducing stimulation before bed, and creating a comfortable sleep environment. Patient verbalized understanding

Medication compliance

Discussed the role and benefits of nighttime medications in managing psychiatric symptoms and promoting restful sleep. Addressed any concerns or questions.

Patient verbalized understanding and agreed to adhere to prescribed nighttime regimen.

Dealing with triggers and stressors


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