Advertisement
| psychosocial assessment documentation example: Introduction to Clinical Mental Health Counseling Joshua C. Watson, Michael K. Schmit, 2019-01-23 Introduction to Clinical Mental Health Counseling presents a broad overview of the field of clinical mental health and provides students with the knowledge and skills to successfully put theory into practice in real-world settings. Drawing from their experience as clinicians, authors Joshua C. Watson and Michael K. Schmit cover the foundations of clinical mental health counseling along with current issues, trends, and population-specific considerations. The text introduces students to emerging paradigms in the field such as mindfulness, behavioral medicine, neuroscience, recovery-oriented care, provider care, person-centered treatment planning, and holistic wellness, while emphasizing the importance of selecting evidence-based practices appropriate for specific clients, issues, and settings. Aligned with 2016 CACREP Standards and offering practical activities and case examples, the text will prepare future counselors for the realities of clinical practice. |
| psychosocial assessment documentation example: The Essentials of Clinical Documentation Maxine Jeffery, 2020-11-03 This clinical manual is an ideal and standardized platform for preparing nursing students with the essential tools for documenting their nursing process. It teaches nursing students how to gather important data about each client in the clinical setting. Using this manual, the student nurse will be able to perform high quality documentation that is accurate and consistent in the client profile and laboratory and diagnostics, and their correlation and significance to the client’s diagnosis or diagnoses. This manual also covers the medication administration record, nursing interventions and rationales, and intake and output forms. The Situation Background Assessment Recommendation (SBAR) form and the use of a concept map complete the list of resources provided. Using this standardized documentation, the student will be able to: • Identify the primary patient data (past and present), diagnosis, and treatment plan. • Analyze patient data correlating and drawing conclusions relevant to patient outcome. • Document finding in a systematic manner. • Interpret diagnostic findings as relate to patient diagnosis This manual is intended for use in medical, surgical, and critical care clinical nursing courses. |
| psychosocial assessment documentation example: Documentation Manual for Occupational Therapy Crystal Gateley, 2024-06-01 The best-selling, newly updated occupational therapy textbook Documentation Manual for Occupational Therapy, Fifth Edition, is made for students and early-career practitioners learning the critical skill of documentation. The workbook format offers students ample opportunities to practice writing occupation-based problem statements and goals, intervention plans, SOAP notes, and other forms of documentation. The Fifth Edition has also been updated to reflect changes in the American Occupational Therapy Association’s Occupational Therapy Practice Framework: Domain and Process, Fourth Edition. What’s included in Documentation Manual for Occupational Therapy: • Numerous worksheets for students to practice individual skills with suggested answers provided in the Appendix • Updated information on coding, billing, and reimbursement to reflect recent Medicare changes, particularly in post–acute care settings • Examples from a variety of contemporary occupational therapy practice settings Included with the text are online supplemental materials for faculty use in the classroom. Instructors in educational settings can visit the site for an Instructor’s Manual with resources to develop an entire course on professional documentation or to use the textbook across several courses. One of the most critical skills that occupational therapy practitioners must learn is effective documentation to guide client care, communicate with colleagues, and maximize reimbursement. The newly updated and expanded Documentation Manual for Occupational Therapy, Fifth Edition, will help students master their documentation skills before they ever step foot into practice. |
| psychosocial assessment documentation example: The OTA’s Guide to Documentation Marie Morreale, 2024-06-01 The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same easy-to-read format from previous editions to aid OTAs in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice. Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout the text. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language. Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes, and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions. New in the Fifth Edition: Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documents Updated information to meet Medicare Part B and other third-party payer requirements Revised clinical terminology on par with current trends Added examples from emerging practice areas Expanded tables along with new worksheets and learning activities Included with the text are online supplemental materials for faculty use in the classroom, this includes: access to supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process. |
| psychosocial assessment documentation example: DocuNotes Cherie Rebar, 2009-04-10 The perfect guide to charting! The popular Davis’s Notes format makes sure that you always have the information you need close at hand to ensure your documentation is not only complete and thorough, but also meets the highest ethical and legal standards. You’ll even find coverage of the nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric, and outpatient nursing. |
| psychosocial assessment documentation example: Illustrated Manual of Nursing Practice , 2002 Completely revised and updated, this broad yet comprehensive edition contains twenty-nine chapters on nursing issues and clinical practice. Topics cover practice and process, documentation, legal issues, health promotion, physical assessment, I.V. therapy, surgical care, and more. Disorders are organized by body system and feature an overview of anatomy and physiology, assessment, diagnostic tests, medication, treatment, and home care, with coverage of care for maternal-neonatal, pediatric, geriatric, emergency, and psychiatric patients. Added features include grabbing nursing procedure graphics, complementary therapies, clinical pathways, and cultural information. Over 1,000 illustrations, charts, and graphs enhance the text, with a new appendix relating Internet sites for nurses. |
| psychosocial assessment documentation example: Social Work Practice With Individuals, Families, and Groups Shelagh Jane Larkin, Jaylene Krieg Schaefer, 2025-01-06 Social Work Practice with Individuals, Families, and Groups: An Integrated Approach serves as a foundational text that supports students through effective practice with multiple levels of client systems, from the classroom to the profession. Authors Shelagh Jane Larkin and Jaylene Krieg Schaefer have integrated the practicum experience throughout the core chapters, emphasizing its role as the first area of social work practice. Developed with both BSW and foundational MSW programs in mind, this text offers an accessible exploration of social work practice with individuals, families, and groups through diverse case studies and practical examples aligned with the 2022 EPAS core competencies. |
| psychosocial assessment documentation example: Admission Assessment Exam Review E-Book HESI, 2020-01-24 Passing the HESI Admission Assessment Exam is the first step on the journey to becoming a successful healthcare professional. Be prepared to pass the exam with the most up-to-date HESI Admission Assessment Exam Review, 5th Edition! From the testing experts at HESI, this user-friendly guide walks you through the topics and question types found on admission exams, including: math, reading comprehension, vocabulary, grammar, biology, chemistry, anatomy and physiology, and physics.The guide includes hundreds of sample questions as well as step-by-step explanations, illustrations, and comprehensive practice exams to help you review various subject areas and improve test-taking skills. Plus, the pre-test and post-test help identify your specific weak areas so study time can be focused where it's needed most. - HESI Hints boxes offer valuable test-taking tips, as well as rationales, suggestions, examples, and reminders for specific topics. - Step-by-step explanations and sample problems in the math section show you how to work through each and know how to answer. - Sample questions in all sections prepare you for the questions you will find on the A2 Exam. - A 25-question pre-test at the beginning of the text helps assess your areas of strength and weakness before using the text. - A 50-question comprehensive post-test at the back of the text includes rationales for correct and incorrect answers. - Easy-to-read format with consistent section features (introduction, key terms, chapter outline, and a bulleted summary) help you organize your review time and understand the information. - NEW! Updated, thoroughly reviewed content helps you prepare to pass the HESI Admission Assessment Exam. - NEW! Comprehensive practice exams with over 200 questions on the Evolve companion site help you become familiar with the types of test questions. |
| psychosocial assessment documentation example: Social Work Practice in Healthcare Karen M. Allen, William J. Spitzer, 2015-04-10 Social Work Practice in Health Care by Karen M. Allen and William J. Spitzer is a pragmatic and comprehensive book that helps readers develop the knowledge, skills, and values necessary for effective health care social work practice, as well as an understanding of the technological, social, political, ethical, and financial factors affecting contemporary patient care. Packed with case studies and exercises, the book emphasizes the importance of being attentive to both patient and organizational needs, covers emerging trends in health care policy and delivery, provides extensive discussion of the Patient Protection and Affordable Care Act, and addresses social work practice across the continuum of care. |
| psychosocial assessment documentation example: The Praeger Handbook of Community Mental Health Practice Doreen Maller, Kathy Langsam, Melissa Jerbian Fritchle, 2013-02-20 This expansive, three-volume set addresses the complexities of interconnectivity, therapeutic capacity, and the competencies needed in order to provide sophisticated and integrated community mental health care—both in the United States and within a global community. The Praeger Handbook of Community Mental Health Practice provides an essential framework that will serve university educators, students, new practitioners, and experienced therapists alike as they adapt to new approaches to community mental health and respond to changing laws governing mental health provision across state, national, and global levels. Volume one considers the structures, challenges, and expectations of community mental health, familiarizing readers with key issues such as service delivery, funding, and key models of intervention and care. Volume two provides an in-depth exploration of the specific issues of working with populations that participate in and benefit from community mental health services, including addiction, school-based services, juvenile and adult justice, and veteran's services. In Volume three, the contributors address specific needs, considerations, and concerns relevant to working in the global community, including disaster services, trauma, working with children, and providing training in international settings. |
| psychosocial assessment documentation example: Charting Made Incredibly Easy! Lippincott, 2012-03-29 In its Fourth Edition, Charting Made Incredibly Easy! provides up-to-the-minute guidelines on documentation in a comprehensive, clear, concise, practical, and entertaining manner. The book reviews the fundamental aspects of charting such as the medical record, the nursing process, and legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting formats currently being used. It also addresses the specific requirements for charting in acute care, home care, and long-term care and rehabilitation settings. Special elements found throughout the book make it easy to remember key points. This edition includes new information on cultural needs assessment, HIPAA, National Patient Safety Goals, and electronic health records. |
| psychosocial assessment documentation example: Documentation , 2007 This full-color handbook is a quick-reference guide to all aspects of documentation for every nursing care situation. It covers current documentation systems and formats, including computerized documentation, and features scores of sample filled-in forms and in-text narrative notes illustrating everything from everyday occurrences to emergency situations. Coverage includes timesaving strategies for admission-to-discharge documentation in acute, outpatient, rehabilitation, long-term, and home care environments and special documentation practices for selected clinical specialties: critical care, emergency, perioperative, maternal-neonatal, and psychiatric. The book includes advice on legal safeguards, dangerous abbreviations, and compliance with HIPAA guidelines and JCAHO requirements. |
| psychosocial assessment documentation example: Introduction to Medical-Surgical Nursing Adrianne Dill Linton, PhD, RN, FAAN, 2015-02-06 The leading medical-surgical text for LPN/LVN students, Linton's Introduction to Medical-Surgical Nursing, 6th Edition offers just the right level of information to equip today's students to effectively care for adults and older adults. Covering both medical-surgical and psychiatric mental health conditions and disorders, this comprehensive text addresses the LPN/LVN's role in a variety of care settings, including acute care and long-term care, with a special emphasis on assignment and supervision responsibilities. It also emphasizes culturally competent care and holistic nursing, while thoroughly covering all relevant NCLEX-PN test plan content No other resource offers the breadth of topics at a level that is so perfectly tailored to the LPN/LVN student. Foundational units on basic concepts related to the health care system, care settings, the nursing process, leadership, nutrition, the older adult, growth and nutrition, legal/ethical considerations, evidence-based nursing care, and many more essential topics, avoid repetition later in the text and create a foundation to build your understanding of disorders by body system. Safety alerts are highlighted throughout the text with a Safety Considerations icon. A separate unit on psychiatric mental health nursing covers psychosocial responses to illness, psychiatric disorders, and substance abuse - eliminating the need for a separate psychiatric mental health nursing text. Content related to the NCLEX-PN test plan is emphasized throughout the text, including health promotion, nutrition, legal/ethical issues, HIPAA, and prevention of medication/medical errors. Separate chapters on common, high-profile disorders (including hypertension, diabetes, and shock), provide an in-depth understanding for patient care. Focus on assignment and supervision helps you assign tasks to nurse assistants, patient care techs, and unlicensed assistive personnel, and makes sure they understand the difference between delegation, management, supervision, and assignment of tasks on the health care team. UNIQUE! In-depth pharmacology coverage includes: the Pharmacology Tutorial covering drug classifications, how drugs work, and nursing responsibilities; Pharmacology Capsules boxes providing medication information, precautions for use, interactions, and side/adverse effects; and Pharmacology and Medications tables including classification, use/action, side/adverse effects, and nursing interventions. A separate unit on gerontologic nursing provides comprehensive coverage of the care of the older adult and related disorders. No other LPN/LVN med-surg text offers as much coverage of this primary patient group. Diagnostic Tests and Procedures tables offer quick reference to MRI, CT, Doppler flow, lumbar puncture tests for neurologic disorders, and much more. Health Promotion Considerations boxes highlight timely wellness and disease prevention topics. Patient Teaching Plans provide bulleted lists of nursing instructions for patients, stressing the role and responsibility of the LPN/LVN to reinforce patient education. Nutrition Considerations boxes are spotlighted at appropriate points throughout the text to emphasize the role that nutrition plays in disease and nursing care. Nursing care plans reinforce the nursing process and focus on critical thinking. Cultural Considerations boxes discuss the importance of providing culturally-competent care related to various clinical situations. Put on Your Thinking Cap boxes allow you to pause and consider the practical implications of what you have just read. Get Ready for the NCLEX-PN Examination! sections at the end of chapters include key points, review questions, and case studies that address the various NCLEX Client Needs categories. NEW! Continued emphasis on evidence-based practice and the most current research findings include specific examples of how scientific evidence can justify and support patient care. NEW! Updated nursing diagnoses all reflect the most current NANDA listings for NCLEX compliance. |
| psychosocial assessment documentation example: Potter and Perry's Fundamentals of Nursing: Second South Asia Edition - E-Book Suresh Sharma, 2017-07-25 Fundamentals of Nursing by Potter and Perry is a widely appreciated textbook on nursing foundations/fundamentals. Its comprehensive coverage provides fundamental nursing concepts, skills and techniques of nursing practice and a firm foundation for more advanced areas of study. This Second South Asia edition of Potter and Perry's Fundamentals of Nursing not only provides the well-established, authentic content of international standards but also caters to the specific curriculum requirements of nursing students of the region. SALIENT FEATURES - Fully compliant to the INC curriculum - Easy-to-read, interesting and involving disposition, which leads the reader through various facets of nursing foundations/ fundamentals - Improved layout, design and presentation - A number of photographs replaced with the Indian ones to provide regional feel to the content - Long Answer and Short Answer questions added at the end of every chapter |
| psychosocial assessment documentation example: Fundamentals Davis Essential Nursing Content + Practice Questions Patricia M Nugent, Barbara A Vitale, 2017-04-20 Up-to-date with the NCLEX-RN® 2016 Test Plan. Too much information? Too little time? Here’s everything you need to succeed in your fundamentals of nursing course and prepare for course exams and the NCLEX®. Succinct content review in outline format focus on must-know information, while case studies and NCLEX-style questions develop your ability to apply your knowledge in simulated clinical situations. You’ll also find proven techniques and tips to help you study more effectively, learn how to approach different types of questions, and improve your critical-thinking skills. |
| psychosocial assessment documentation example: Assessment and Care of Patients Jan Allison, 2002 As you're probably well aware, the patient assessment and care of patients standards have been perennial top Type I's in recent years. But did you know that these standards now encompass 4 of the top 5 spots on the JCAHO's Top Type I's list? It's about time for a resource that explains exactly how to comply with these challenging standards! That's why we're excited to introduce the Assessment and Care of Patients: Your Guide to JCAHO Compliance book. This comprehensive, how-to resource contains all the information you need to not only achieve greater survey success, but also to demonstrate better patient outcomes through improved compliance. Assessment and Care of Patients: Your Guide to JCAHO Compliance is designed to provide you with an easy-to-follow road map through two of the most complex and problematic CAMH chapters related to patient assessment. It incorporates all the information you need to develop a better understanding of the standards and even includes specific surveyor questions and findings from recent surveys! |
| psychosocial assessment documentation example: Neurodiversity and College Jane Thierfeld Brown, Lorre Wolf, Amy Rutherford-Moody, Lisa King, Ruth Kukiela Bork, 2025-05-05 Help to Make the College Experience a Great One for Your Autistic Student! Sending a child off to college is a daunting experience for most parents, but if your child is neurodiverse, the challenge is magnified. Even students with excellent academic preparation face difficulties in higher education, primarily related to communication, social skills, and sensory-based issues. This parent-friendly book, written by parents who also are autism professionals, takes fear and mystery out of the college experience. The new edition takes a detailed look at: • Changes and challenges for parents in college applications • New and expanding college programs for autistic students • The role of parents in the transition from being the advocate to supporting their student in self-advocating Advance Praise for Neurodiversity and College Targeted for parents supporting autistic and neurodivergent individuals heading toward higher education and professionals within the field, this state-of-the-art resource has a plethora of easy to implement, practical solutions for students applying to, attending, and transitioning out of college. This is the book I wish my parents had as they were guiding me through my education. — Stephen Shore, Ed.D, Clinical Associate Professor of Special Education, Adelphi University; internationally known author, consultant, and presenter on autism and neurodiversity issues; autistic individual |
| psychosocial assessment documentation example: Guidelines for Cardiac Rehabilitation Programs American Association of Cardiovascular & Pulmonary Rehabilitation, 2021 Guidelines for Cardiac Rehabilitation Programs, Sixth Edition, offers procedures for providing patients with low-cost, high-quality programming that moves them toward a lifelong commitment to disease management. |
| psychosocial assessment documentation example: Pulmonary Rehabilitation - E-Book John E. Hodgkin, Bartolome R. Celli, Gerilynn A. Connors, 2023-06-02 Approx.592 pagesApprox.592 pages - New chapters covering new advances and discoveries in respiratory care: - Systemic Effects of Chronic Obstructive Pulmonary Disorders - Complementary Alternative Medicine for Patients with Chronic Lung Disease - Pulmonary Rehabilitation and Lung Volume Reduction Surgery - Management of and Reimbursement for Pulmonary Rehabilitation Services - Exercise and Pulmonary Hypertension - New and revised illustrations and photographs. - Expanded coverage of patients with respiratory diseases other than COPD as well as pediatric pulmonary patients. - New and revised pedagogy including chapter outlines and updated objectives - Enhanced chapters - Addresses the latest research and reports including The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report recommending pulmonary rehabilitation. |
| psychosocial assessment documentation example: When Seniors are Abused Myrna Reis, Daphne Nahmiash, 1995 |
| psychosocial assessment documentation example: The Case Manager's Handbook Catherine M. Mullahy, 2013-06-20 Written by renowned author Catherine Mullahy, The Case Manager’s Handbook, Fifth Edition is the ultimate how-to guide for case managers. This practical resource helps case managers build fundamentals, study for the Certified Case Manager (CCM) exam, and most importantly, advance their careers after the exam. Written for all professionals in all practice settings in case management, it uses real-life examples and an easy-to-read, conversational style to examine the case management process while presenting practical procedural information. An excellent daily reference and training guide for new case managers and seasoned professionals in various setting, The Case Manager’s Handbook, Fifth Edition is the “go-to” resource for facing the day-to-day challenges of case management, especially as the nation navigates through the many changes introduced by the landmark Patient Protection and Affordable Care Act. Significantly updated and revised, it contains eight new chapters: * Hospital Case Management: Changing Roles and Transitions of Care * Patient Centered Medical Home, ACOs, Health Exchanges * Evidence-Based Practice * Public Sector Reimbursement * Predictive Modeling * Pain Management * Health Technology, Trends, and Implications for Case Managers * The Affordable Care Act of 2010: Implications for Case Managers Included with each new print book is an Access Code for a Navigate Companion Website for students with objectives, multiple choice questions, and bonus appendices. |
| psychosocial assessment documentation example: Varcarolis' Foundations of Psychiatric-Mental Health Nursing - E-Book Margaret Jordan Halter, 2021-07-08 **Selected for Doody's Core Titles® 2024 with Essential Purchase designation in Psychiatric**Prepare for psychiatric nursing care with this comprehensive, evidence-based text! Varcarolis' Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach, 9th Edition makes it easy to understand the complexities of psychiatric disorders and how to provide quality mental and behavioral health care. Clinical chapters follow the nursing process framework and progress from theory to application, preparing you for practice with real-world examples. Other notable features include illustrated explanations of the neurobiology of disorders, DSM-5 criteria for major disorders, and nursing care plans. From clinical nurse specialist and lead author Dr. Margaret Jordan Halter, this bestselling text includes new Next Generation NCLEX® content to prepare you for success on your PMHN certification exam. - Case Study and Nursing Care Plan boxes include real-life vignettes of patients with specific psychiatric disorders. - Evidence-Based Practice boxes describe recent research studies and how their findings affect nursing practice. - Six-step nursing process is followed in clinical chapters, providing consistent guidelines for comprehensive assessment and intervention. - Learning features include key terms and concepts, key points to remember, critical thinking, and chapter reviews. - Conversational, mentor-like writing style reinforces important information and helps in applying textbook content to the clinical setting. - Coverage of therapeutic communication techniques and nontherapeutic communication provides tips to help you build patient interaction skills. - Assessment Guidelines summarize the steps of patient assessment for various disorders. - Considering Culture boxes discuss the importance of person-centered care in providing competent care to diverse populations in various clinical situations. - Patient and Family Teaching boxes focus on the nurse's role in helping patients and families understand psychiatric disorders, treatments, complications, and medication side effects. |
| psychosocial assessment documentation example: Varcarolis Essentials of Psychiatric Mental Health Nursing - E-Book Chyllia D Fosbre, 2022-04-26 **Selected for Doody's Core Titles® 2024 in Psychiatric**Gain the essential knowledge and skills you need to succeed as a psychiatric nurse! Varcarolis' Essentials of Psychiatric-Mental Health Nursing: A Communication Approach to Evidence Based Care, 5th Edition provides a concise, easy-to-understand guide to today's leading psychiatric theories and therapeutic modalities. Emphasizing evidence-based care, the book balances coverage of scientifically based treatment approaches with insights into effective communication skills, so you will be prepared to offer the best possible care when you enter practice. Written by nursing expert Chyllia D. Fosbre, this edition adds new Next Generation NCLEX® (NGN) examination-style case studies to help you develop critical thinking skills and prepare for the NGN exam. - Applying Critical Judgment questions introduce clinical situations in psychiatric nursing and encourage critical thinking. - Neurobiology of the Brain feature includes illustrations depicting how a disorder affects brain function and how drugs help to mitigate the symptoms. - Applying Evidence-Based Practice boxes in the clinical chapters pose a question, walk you through the process of gathering evidence-based data from a variety of sources, and present a plan of care based on the evidence. - Vignettes describe real-world psychiatric patients and their disorders. - Assessment Guidelines boxes summarize the steps of patient assessment for various disorders. - Applying the Art boxes offer clinical scenarios demonstrating the interaction between a nurse and a patient, the nurse's perception of the interaction, and the mental health nursing concepts in play. - Potential Nursing Diagnoses tables list possible nursing diagnoses for a particular disorder, based on ICNP terminology, along with the associated signs and symptoms. - Nursing Interventions tables list interventions for a given disorder or clinical situation, along with rationales for each intervention. - DSM-5 Criteria boxes identify the diagnostic criteria for most major disorders. - Integrative Care boxes highlight the different types of therapy may be used to enhance treatment. - Giddens Concept boxes at the beginning of each chapter tie concepts to the topics to be discussed. - NEW! Next Generation NCLEX® (NGN) examination-style case studies are included in the clinical disorders chapters to promote critical thinking and help to prepare you for the NGN exam. |
| psychosocial assessment documentation example: Tabbner's Nursing Care 2 Vol Set - E-Book Epub Gabrielle Koutoukidis, Kate Stainton, 2024-11-19 Must-have resource for all future Enrolled NursesTabbner's Nursing Care is the main resource for Diploma of Nursing students and instructors. This well-established and highly respected book provides the knowledge and skills learners need to qualify as Enrolled Nurses. Written by a highly qualified team of editors and contributors, the book equips the learner to provide safe, competent and person-centred care. It teaches and prepares learners to apply critical and reflective thinking to decision-making, use healthcare technology and work as part of a healthcare team in a variety of settings. Complete with an accompanying workbook and a host of features to support and facilitate teaching and learning, Tabbner's Nursing Care is the ideal contemporary, evidenced-based resource to develop competent and safe Enrolled Nurses of the future. - Reflects the current context and scope of practice for Enrolled Nurses - Takes a person-centred care approach and supports learners to become safe and competent Enrolled Nurses - Builds clinical reasoning, critical thinking and problem-solving skills - Full-colour content to support teaching and learning - Includes Nursing Care Plans, Critical Thinking Exercises, Case Studies, Progress Notes, Decision-Making Framework Exercises, Clinical Skills with rationales and Review Exercises New to this edition - New skills covering: - Removal of a drain tube - Urinary catheterisation (male) - Focused pain assessment - Care of the person after death - Content covering health informatics and technology, LGBTQIA+ representation and COVID-19 - New chapter on readiness for practice Instructor resources on Evolve: - Answer guides for Case Studies, Critical Thinking Exercises, Decision-Making Framework Exercises, Review Questions - Clinical Cases case studies - Clinical Skills videos - Image collection - PowerPoint slides - Test bank - Weblinks Learner and instructor resources on Evolve: - Answer guides for Case Studies, Critical Thinking Exercises, Decision-Making Framework Exercises, Review Questions - Clinical Cases case studies - Clinical Skills videos - Weblinks |
| psychosocial assessment documentation example: Introductory Mental Health Nursing Cynthia A. Kincheloe, 2023-09-15 Updated, easy to read, and designed specifically for today’s LPN/LVN students, Introductory Mental Health Nursing, 5th Edition, makes the realities of mental health nursing approachable and prepares students to confidently manage clients’ mental healthcare needs across a wide range of care settings. This extensively revised 5th Edition delivers clear, comprehensive, clinically relevant information reflecting the care needs of a diverse client population. Powerful built-in study aids strengthen students’ critical thinking and clinical application capabilities to prepare them for any challenge they may encounter. |
| psychosocial assessment documentation example: The Case Manager’s Handbook Catherine M. Mullahy, 2016-05-23 Written by renowned author Catherine M. Mullahy, The Case Manager’s Handbook, Sixth Edition is an indispensable guide for case managers. Presented in an accessible and conversational style, this practical resource helps case managers learn the fundamentals, study for the Certified Case Manager (CCM) exam, and advance their careers after the exam. Completely updated and enhanced with information on the latest developments affecting case management, it reflects the rapidly changing healthcare landscape, including the significant effects of the Affordable Care Act (ACA). The Sixth Edition includes new chapters on pediatric case management, workers’ compensation case management, key factors driving today’s healthcare system, the case manager’s role in the era of value-based health care, case management and healthcare provider strategies for managing the high-risk or high-cost patient, and transformative healthcare approaches for the millennial generation. |
| psychosocial assessment documentation example: A Practical Guide To Care Planning In Health And Social Care Lloyd, Marjorie, 2010-03-01 This accessible guide takes the mystery and fear out of care planning and will help you to develop a person centred approach to delivering good quality nursing care in all clinical settings. The book explores each part of the care planning process in detail and provides opportunities for you to reflect upon practice and to develop effective skills. |
| psychosocial assessment documentation example: Case Studies in Nursing Case Management Suzanne Smith Blancett, Dominick L. Flarey, 1996 Case Studies in Nursing Case Management provides portrayals of health care organizations around the nation that have successfully implemente d case management programs. It reports on how case management is being used in inpatient, ambulatory, operating room, intensive care, home h ealth, and subacute settings. Specific populations such as pediatric, maternity, dialysis, geriatric, psychiatric, and AIDS/HIV patients are also addressed. Case managers' roles in managed care and community-ba sed settings as well as in insurance companies are described. |
| psychosocial assessment documentation example: Manual of Inpatient Psychiatry Michael I. Casher, Joshua D. Bess, 2020-03-26 Inpatient units treat some of the most clinically challenging psychiatric patients. Clinicians must carefully balance patients' rights with safety concerns of violence and suicide. This updated manual is compact and practical, addressing the common questions and issues clinicians face in day-to-day practice. Chapters are organised around the diagnoses found on inpatient psychiatric units, allowing readers to find their area of interest quickly. A user-friendly question and answer format anticipates commonly asked questions, and tables provide easily accessible information, including diagnostic criteria and medication effects. Incorporating advances in the field over the past decade, chapters review new treatments including ketamine use and chronotherapy, as well as the most recent evidence-based approaches for patients with borderline personality disorder. Drawing on the authors' wealth of experience, their recommendations for best practice and their treatment philosophies will be valuable for all healthcare professionals working in mental health. |
| psychosocial assessment documentation example: Breast Cancer and Gynecological Cancer Rehabilitation Adrian Cristian, 2020-09-15 Breast Cancer and Gynecological Cancer Rehabilitation, edited by Adrian Cristian, MD, MHCM, provides today's clinicians with a concise, accessible resource covering the holistic rehabilitation of breast cancer patients. Beginning with a review of epidemiology, genetics, and pathophysiology of breast cancer, it then covers clinical assessment and treatment options before providing comprehensive coverage of rehabilitation. Containing practical information, best practices, and the latest advances and research, this book is a valuable reference for physical medicine and rehabilitation physicians and residents, as well as occupational and physical therapists. - Provides a clear understanding of the current medical, surgical, and radiation treatments for breast cancer. - Covers the whole spectrum of breast cancer rehabilitation, including the role of physical and occupational therapy, treatment of anxiety and depression, pain syndromes, integrative care, nutritional rehabilitation, palliative care, and more. - Offers a timely and convenient resource written by leading experts in breast cancer and rehabilitation. |
| psychosocial assessment documentation example: The Oxford Textbook of Palliative Social Work Terry Altilio, Shirley Otis-Green, John G. Cagle, 2022 It is so important to advocate for things that may not always seem possible. Getting to work with patients/families at the end of their life is the ultimate honor. - Lauren G Markham, MSW, LCSW, APHSW-C In this work, one witnesses both depths of human suffering and heights of human transcendence that can inspire both awe and fear. At those times, I have found that surrendering my need to be an expert and instead, allow myself to simply be a human is the wisest action. - Kerry Irish, LCSW, OSW-C, FAOSW-- |
| psychosocial assessment documentation example: Physical Therapy Documentation Mia Erickson, Mia L. Erickson, Rebecca McKnight, Ralph Utzman, 2008 Complete & accurate documentation is one of the essential skills for a physical therapist. This book covers all the fundamentals & includes practice exercises & case studies throughout. |
| psychosocial assessment documentation example: Nursing Interventions & Clinical Skills - E-Book Anne G. Perry, Patricia A. Potter, Wendy R. Ostendorf, 2015-01-08 Master nursing skills with this guide from the respected Perry, Potter & Ostendorf author team! The concise coverage in Nursing Interventions & Clinical Skills, 6th Edition makes it easy to master the clinical skills required in everyday nursing practice. Clear guidelines address 159 basic, intermediate, and advanced skills — from measuring body temperature to insertion of a peripheral intravenous device — and step-by-step instructions emphasize the use of evidence-based concepts to improve patient safety and outcomes. Its friendly, easy-to-read writing style includes a streamlined format and an Evolve companion website with review questions and handy checklists for each skill. - Coverage of 159 skills and interventions addresses basic, intermediate, and advanced skills you'll use every day in practice. - UNIQUE! Using Evidence in Nursing Practice chapter provides the information needed to use evidence-based practice to solve clinical problems. - Safe Patient Care Alerts highlight unusual risks in performing skills, so you can plan ahead at each step of nursing care. - Delegation & Collaboration guidelines help you make decisions in whether to delegate a skill to unlicensed assistive personnel, and indicates what key information must be shared. - Special Considerations indicate additional risks or accommodations you may face when caring for pediatric or geriatric patients, and patients in home care settings. - Documentation guidelines include samples of nurses' notes showing what should be reported and recorded after performing skills. - A consistent format for nursing skills makes it easier to perform skills, always including Assessment, Planning, Implementation, and Evaluation. - A Glove icon identifies procedures in which clean gloves should be worn or gloves should be changed in order to minimize the risk of infection. - Media resources include skills performance checklists on the Evolve companion website and related lessons, videos, and interactive exercises on Nursing Skills Online. - NEW coverage of evidence-based techniques to improve patient safety and outcomes includes the concept of care bundles, structured practices that have been proven to improve the quality of care, and teach-back, a new step that shows how you can evaluate your success in patient teaching. - NEW! Coverage of HCAHPS (Hospital Care Quality Information from the Consumer Perspective) introduces a concept now widely used to evaluate hospitals across the country. - NEW! Teach-Back step shows how to evaluate the success of patient teaching, so you can be sure that the patient has mastered a task or consider trying additional teaching methods. - NEW! Updated 2012 Infusion Nurses Society standards are incorporated for administering IVs, as well as other changes in evidence-based practice. - NEW topics include communication with cognitively impaired patients, discharge planning and transitional care, and compassion fatigue for professional and family caregivers. |
| psychosocial assessment documentation example: Essentials of Psychiatric Mental Health Nursing Elizabeth M. Varcarolis, 2012-09-26 This focused approach to psychiatric mental health provides you with an uncomplicated way to understand the often-intimidating subject of psychiatric nursing. Inside you'll find two themes of psychiatric mental health nursing: the How of Communication and the Why of Evidence. You will also find easy-to-understand explanations of the research that applies to psychiatric nursing issues and how to incorporate this evidence into everyday care. |
| psychosocial assessment documentation example: Transgender and Gender Diverse Persons Alfred F. Carlozzi, Kurt T. Choate, 2018-12-12 Transgender and Gender Diverse Persons offers mental health professionals and other caregivers information and best practices for working with transgender and gender diverse persons and their families. In each chapter, experts from a variety of fields provide an accessible introduction to medical, legal, educational, and spiritual care for transgender and gender diverse adults and youth within a range of contexts, including communities and schools in urban and non-urban settings. Appendices include helpful suggestions for online resources, as well as additional reading for practitioners, clients, and their families. With rich examples and personal narratives woven throughout, this is an essential reference for mental health professionals, as well as other service providers, educators, and family members seeking to address the needs of transgender and gender diverse persons in an up-to-date, inclusive manner. |
| psychosocial assessment documentation example: A Practical Guide to the Evaluation of Child Physical Abuse and Neglect Angelo P. Giardino, Michelle A. Lyn, Eileen R. Giardino, 2018-12-11 The impact of child maltreatment on victims, families, and society—from immediate medical care and legal services to long-term mental health care and law enforcement—cannot be understated. And it remains a severe problem in spite of increasing public awareness and stricter laws. To keep up with growing body of professionals staying informed on this subject, the third edition of A Practical Guide to the Evaluation of Child Physical Abuse and Neglect assists the reader in recognizing abuse/neglect (exclusive of sexual abuse) in children and youth, and determining its extent. Illustrated with clinical photographs, the Guide details systematic evaluation procedures, explains the tasks of an evaluation team, and expands and updates the knowledge base in these and other major areas: Specific injuries, including burns, bruises, fractures, and head and abdominal injuries Malnourishment and other forms of neglect Medical child abuse (previously known as Munchausen Syndrome by Proxy) Maltreatment of children with special health care needs Domestic partner violence Prevention strategies, psychosocial assessment, collaborations with law enforcement and the courts, and more The new edition of A Practical Guide to the Evaluation of Child Physical Abuse and Neglect offers expert information useful to practitioners across professional domains: public health professionals in maternal and child health and school settings; physicians and nurses; clinical social workers, child psychologists, and school psychologists; and attorneys and law enforcement personnel. |
| psychosocial assessment documentation example: deWit's Fundamental Concepts and Skills for Nursing - First South Asia Edition-E-Book Ambika Ravindran, 2017-06-24 Fundamental Concepts and Skills for Nursing, First South Asia Edition provides all the basic theoretical and applied knowledge that the LPN/LVN nurse needs to practice in an expanded number of care settings, such as the community clinic, physician's office, long-term care facility, home, and acute-care hospital setting. With an extensive art program and thorough discussion of QSEN, this text addresses topics like the physical and psychosocial needs of the patient, critical thinking for problem solving and clinical judgment, and communication — all within a strong nursing process framework. The accessible, friendly, and clear writing style appeals to students and instructors, and its rich ancillary package, including NCLEX-PN® review questions, gives students an edge on learning fundamentals. - Concept maps give a visual example of concepts addressed in the text, help you visualize difficult material, and illustrate how a disorder's multiple symptoms, treatments, and side effects are associated. - Over 110 skills and steps, featuring sample documentation examples and Home Care Considerations boxes where appropriate, present step-by-step procedures in an action/rationale format. - Life Span Considerations: The Older Adult highlight changes that occur with aging and how they affect nursing care by LPN/LVNs working in community and long-term care. - Easy-to-follow reading level and text organization presents information from simple to most complex, making it perfect for lower level students and those speaking English as a second language. - Numbered objectives, divided by theory and clinical practice, provide a framework for content. - Cultural Considerations cover biocultural variations, as well as health promotion for specific ethnic groups, so you provide culturally competent care. - Health Promotion and Patient Teaching boxes include guidelines to prevent illness, promote health, and develop self-care strategies. - Nursing process framework features application of the nursing process and nursing care plans to reinforce application of the nursing process in the clinical setting. - Think Critically boxes encourage you to synthesize information and apply concepts to practice. - Home Care Considerations boxes highlight the necessary adaptations of nursing skills and techniques for the patient in the home care setting. - Communication boxes present examples of nurse-patient dialogues and instructive therapeutic communication techniques. - Over 20 nursing care plans, which include critical thinking questions at the end of the text, provide you with a model for planning patient care. - Clinical chapters provide an overview of structure and function to give you a refresher in related anatomy and physiology, including a section on aging. - Key terms include phonetic pronunciations, which are helpful for ESL students, and text page references to find the definition. - Standard LPN Threads features include helpful characteristics such as full-color design, key terms, numbered objectives, key points, critical thinking questions, critical thinking activities, glossary, and references. |
| psychosocial assessment documentation example: Wound Care Essentials Sharon Baranoski, Elizabeth A. Ayello, 2008 Written by two well-known wound care specialists and an interdisciplinary team of experts, this handbook is essential for all professionals involved in wound care, including nurses, physical therapists, physicians, podiatrists, and long-term care professionals. The book provides practical, comprehensive guidelines for assessment and management of both common and atypical wound problems and covers many topics not sufficiently addressed in other texts, such as sickle cell wounds, amputation, gene therapy, and the specific wound care needs of special populations. Features include more than 100 photographs and illustrations, recurring icons such as Evidence-Based Practice and Practice Points, case studies, and review questions. |
| psychosocial assessment documentation example: Charting by Exception Laura J. Burke, Judy Murphy, 1988 A time-efficient and cost-effective method of documentation of nursing care through a system of charting by exception (the documentation of abnormal or significant findings using a standard normal base) is described in this book. The method eliminates time-consuming documentation of normal findings and repetitious information, allowing the nurse to spend less time at the desk and more time caring for patients. |
| psychosocial assessment documentation example: "Code of Massachusetts regulations, 2016" , 2016 Archival snapshot of entire looseleaf Code of Massachusetts Regulations held by the Social Law Library of Massachusetts as of January 2020. |
Psychosocial - Wikipedia
The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and …
What is psychosocial? | Understanding Human Connections
Psychosocial refers to the interplay between psychological and social factors affecting an individual’s mental health and behavior. Psychosocial elements play a pivotal role in shaping …
Erik Erikson’s Stages of Psychosocial Development - Simply Psychology
Apr 18, 2025 · Erikson’s theory outlines eight stages of psychosocial development, from infancy to adulthood. At each stage, individuals face a conflict, such as trust vs. mistrust, which shapes …
25 Psychosocial factors Examples - Helpful Professor
Sep 8, 2023 · Psychosocial factors refer to factors that influence individual behavior and well-being which have two elements: a psychological element and a social element.
The invention of the psychosocial: An introduction - PMC
They address four major questions: How is the psychosocial imagined? What tools are involved in making it visible? What values are encoded in the concept and how is the relationship …
PSYCHOSOCIAL Definition & Meaning - Merriam-Webster
The meaning of PSYCHOSOCIAL is involving both psychological and social aspects. How to use psychosocial in a sentence.
Psychosocial Development: Stages, Principles, and More
Sep 22, 2023 · Psychosocial development describes how a person's personality develops, and how social skills are learned from infancy through adulthood. In the 1950s, psychologist Erik …
Psychosocial Theory - an overview | ScienceDirect Topics
Psychosocial theory explains changes in self-understanding, social relationships, and one’s relationship to society from infancy through later life. Erik Erikson is the primary theorist …
PSYCHOSOCIAL | English meaning - Cambridge Dictionary
Pragmatic randomized trial of antenatal intervention to prevent postnatal depression by reducing psychosocial risk factors. Psychosocial challenge tests as well as pharmacological probes …
Psychological vs. Psychosocial - What's the Difference ... - This vs.
Psychosocial psychologists study how social interactions, relationships, and cultural norms impact an individual's thoughts, emotions, and behaviors. They explore how societal factors such as …
Psychosocial - Wikipedia
The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and …
What is psychosocial? | Understanding Human Connections
Psychosocial refers to the interplay between psychological and social factors affecting an individual’s mental health and behavior. Psychosocial elements play a pivotal role in shaping …
Erik Erikson’s Stages of Psychosocial Development - Simply Psychology
Apr 18, 2025 · Erikson’s theory outlines eight stages of psychosocial development, from infancy to adulthood. At each stage, individuals face a conflict, such as trust vs. mistrust, which shapes …
25 Psychosocial factors Examples - Helpful Professor
Sep 8, 2023 · Psychosocial factors refer to factors that influence individual behavior and well-being which have two elements: a psychological element and a social element.
The invention of the psychosocial: An introduction - PMC
They address four major questions: How is the psychosocial imagined? What tools are involved in making it visible? What values are encoded in the concept and how is the relationship …
PSYCHOSOCIAL Definition & Meaning - Merriam-Webster
The meaning of PSYCHOSOCIAL is involving both psychological and social aspects. How to use psychosocial in a sentence.
Psychosocial Development: Stages, Principles, and More
Sep 22, 2023 · Psychosocial development describes how a person's personality develops, and how social skills are learned from infancy through adulthood. In the 1950s, psychologist Erik …
Psychosocial Theory - an overview | ScienceDirect Topics
Psychosocial theory explains changes in self-understanding, social relationships, and one’s relationship to society from infancy through later life. Erik Erikson is the primary theorist …
PSYCHOSOCIAL | English meaning - Cambridge Dictionary
Pragmatic randomized trial of antenatal intervention to prevent postnatal depression by reducing psychosocial risk factors. Psychosocial challenge tests as well as pharmacological probes …
Psychological vs. Psychosocial - What's the Difference ... - This vs.
Psychosocial psychologists study how social interactions, relationships, and cultural norms impact an individual's thoughts, emotions, and behaviors. They explore how societal factors such as …
