Nursing Daily Charting


Psychiatric Diagnosis:

Medical and (or) physical problems:

Psychosocial and Environmental Problems: (problems with primary support group, education, occupational, housing, economic, access to health care)

Presenting Problem

Reason for initial hospitalization (Client’s own words):

Current stressors:

Mental Status Examination

Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup):

Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other):

Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent):

Affect (blunted, flat, guarded, labile, expansive, sad, or other):

Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other):

Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other):

Thought Content:

Suicide Ideation (plan and/or intent):

Homicidal Ideation (plan and/or intent):

Hallucinations (auditory, visual, olfactory, gustatory, tactile):

Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania):

Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other):

Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other):

Cognition (orientation, memory recall, concentration, attention span):



Coordination/gait/notable movement:


Cultural issues, familial concerns and religious affiliation that may affect his/her care:

Support System:

Current Physical Health

How would you describe your health:  Excellent       Average           Good   Poor    

Activity-Exercise-Sleep-Rest Pattern:

Substance Abuse

SubstanceAmount/FrequencyDurationLast Used

Withdrawal symptoms:

Other Addictions (gambling, sex, internet, shopping, internet, etc.):

Nursing Diagnosis

Potential Nursing Diagnosis (pick one, must be NANDA):

Planning (one patient goal):

Nursing Interventions (Assess, Do, Teach):




Evaluation (patient response to interventions and teachings):  Met, not met, or partially met


Medication (Generic / Trade) Dose / Route / Frequency / Range 
Side Effects Food and Drug Interaction 
Purpose / Rationale for the Patient 
Medication (Generic / Trade) Dose / Route / Frequency / Range 
Side Effects Food and Drug Interaction 
Purpose / Rationale for the Patient 
Medication (Generic / Trade) Dose / Route / Frequency / Range 
Side Effects Food and Drug Interaction 
Purpose / Rationale for the Patient 

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