Legal & Professional Standards
If the patient is on a Form 1, they can refuse treatment.
Yes, unless they have a POA/SDM
What should be documented in patients chart when doing the MSE
Behavior, not the interpretation of behavior
Document the behavior observed, then interpret it and give others the opportunity to interpret it.
Assess and Document every shift
CSSR-S Suicide Risk
Patient declined medication after education. What documentation is required?
Update MAR
Note it in the narrative note, with the actions taken.
use 'declined" instead of refused
Patient is very agitated and aggressive. Uncooperative.
Poorly documented
Patient leaving AMA: what documentation is required?
legal status, patient statements in verbatim, risk assessment, physician notification, actions taken,
How often should an MSE be completed or updated on a patient who is admitted under mental health service?
At a minimum, once per shift, and more frequently if there is a change in behavior, risk, medication, or clinical status.
Patient reported intent and a plan, but says they don't want to discuss the plan. What should be documented
Detailed assessment
Nursing interventions/actions initiated
Escalation process
Reported to whom?
A patient declined treatment but is incapable. What documentation is required?
Document incapacity, SDM consent, education provided, and patient response and actions taken to provide treatment
Patient paranoid and delusional
Poorly documented
Instead, document the behavior, not the interpretation. Example: Patient stated, “Staff are talking about me and watching me through the cameras.” Appeared guarded, frequently scanned the room, and avoided eye contact
As an officer In Charge, what do you verify in the forms
Expiry date and Time, Name and address of the patient written legibly and correctly, boxes checked.
Put your signature and seal.
How would you objectively document psychomotor agitation?
Document observable behaviors such as pacing, restlessness, clenched fists, or inability to remain seated, rather than labeling the patient as agitated.
Aggressive:
manipulative:
Use trauma informed language and rewrite these words.
Aggressive: shouting, pacing, clenched fists, screaming, yelling, etc Explain the behavior
manipulative: seeking reassurance, repeated requests
What documentation is required for PRN medication administration?
Administration in MAR, reason for administration, and effectiveness of PRN after administration with details.
Patient threatening staff
Poorly documented
Instead, document the behavior, not the interpretation. Example: Patient shouted, “I will punch you if you come closer,” while stepping toward the staff with fists clenched. Staff maintained distance and initiated Code white.
You sent the patient on leave of absence. What documentations are required?
Document the type of leave, duration, accompaniment, risk assessment prior to leave, meds sent, and education provided.
A patient states, “The TV is sending me messages.” Which MSE domains does this involve, and how would you chart it?
Thought content
Document the patient’s statement verbatim.
Patient reported cough, body pain, and sniffles. What actions and documentation are required?
Complete covid screening/Respiratory illness screening
Initiate precautions
Notify IPAC
Notify the team lead
"I feel safer when staff explain things before touching me". Loud noises increased patient distress. Verbal de-escalation and validation were attempted prior to PRN administration.
What do these documentation highlight?
Trauma Informed care
Poor insight and judgement
poorly documented
Instead, document the behavior, not the interpretation, as the patient denied the need for treatment and attempted to leave the unit without authorization despite the explanation of risks. Required redirection back to the unit by the protection Officer.
You gave your patient the wrong medication. As a nurse, what documentation and notifications are required?
Notify the patient about the error
notify MRP
Notify team lead
Complete RL
add narrative note with details of action taken.
"Thought process disorganized".
Is it behavior or the interpretation of behavior?
What is missing?
Interpretation of behavior
details of behavior to interpret is missing
The patient is placed on a waist restraint. What documentation is required, and at what frequency?
Behavior warranted for restraint
Alternative interventions tried, patient responses,
Document Q15 until behavior stabilizes, Q 30 x 2 hours, and Q1hour after, until removed.
What are the ten domains of verbal de-escalation?
Respect personal space
Do not be provocative
Establish verbal contact
Be concise
Identify wants and feelings
Listen closely to what the patient is saying
Agree or agree to disagree
Lay down the law and set clear limits
Offer choices and optimism
Debrief the patient and staff.
Patient calmed down after meds.
Poorly documented
Following administration of PRN medication at 1430, the patient was seated quietly in the room, speech normal rate and volume, and denied ongoing distress at 1500.