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Clinical Assignment Packet for
Mental Health Nursing
.
Contents:
Clinical Limitations
Medication Knowledge Base
Required Assignments
Clinical Reflective Journal
Therapeutic Communication Definitions
Mental Status Exam
Mental Health Nursing Assessment
Medication Preparation Log (MPL)
Interaction Process Recording (IPR) Instructions
IPR Cover Sheet, Analysis and Evaluation
Nursing Care Plan Forms
**Please note that additional care plan information/forms are available as a separate
document on the LRC website.
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Limitations to Clinical Practice
During this clinical rotation, students may, with preceptors’ consent and supervision, assume
responsibility for all the nursing activities within the preceptors’ roles. The following are
exceptions to this rule.
Students may not do the following:
1. Witness any consent forms or advance directive forms.
2. Administer any medications in the mental health setting.
3. Perform any task that requires certification or advanced instruction (i.e., arterial blood
gas (ABG) puncture, chemotherapy, removal of central venous catheter,
interpretation/monitoring of EKGs).
4. Take physician orders either verbally or by phone.
5. Transcribe physician orders.
6. Initiate invasive monitoring.
7. Regulated epidural analgesia.
8. Remove epidural catheters.
9. Remove surgically inserted drains and/or tubes (e.g. Jackson-Pratt drains, Hemovac
drains) without direct supervision by a Registered Nurse.
10. Solely monitor patient during and following conscious sedation.
11. Witness wasting or the sign out controlled medications in Accudose, Pyxis or Meditrol
medication delivery systems.
12. Perform end of shift controlled medication count (if applicable).
13. Have controlled medication keys in their possession (if applicable).
14. Verify blood products and/or witness blood administration forms.
15. Perform any invasive procedure on each other in any setting (i.e., injections,
catheterization, IV starts).
16. Perform any task during a code situation, except those skills learned in BLS.
17. Interventions that the facility restricts the student from performing.
18. Any skill/procedure that has not been covered in a nursing lab.
19. Any task outside the RN scope of practice as identified by facility.
Any questions regarding specific procedures or responsibilities should be directed to the Denver
School of Nursing faculty. Students are expected to maintain standards of care of the facility and
function within the scope of their knowledge, skills, and abilities.
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Medication Knowledge Base

Drug required knowledge is mandatory for each medication prescribed for each assigned
patient. Students will not be administering medications to patients in this clinical experience.

If you can memorize and retain information without writing it down, you may do this, but
you may not pass medications without this knowledge at hand – use of reference materials at
the cart side or at the PYXIS is time prohibitive and must be a rare back-up system.

Student must be prepared to recite required knowledge base (as outlined below) at med-cart
or PYXIS as requested by instructor.

Using a drug knowledge tool is useful in review for future clinical rotations and for NCLEX
review and to prepare for different patients.

Medication knowledge base MUST include the MINIMAL information as reflected on the
following page-Medication Preparation Log (MPL)

‘Must know’ could be ‘Take pulse’ for drugs affecting heart rate or rhythm, ‘Take BP’ for
drugs affecting BP, ‘Check K+’ before administering potassium supplements, ‘Check BG’
for insulin or other drugs affecting BG, etc.
Required Assignments
ADN:





1 Complete Mental Health Nursing Assessment, including the Medication Preparation Log
2 Interpersonal Process Recordings (IPR)
1 Nursing care plan with at least one nursing diagnosis
Weekly journaling, per instructor preference
Students MUST do Reflective Logs in evaluation packets
BSN:





2 Complete Mental Health Nursing Assessments, including the Medication Preparation Logs
2 Interpersonal Process Recordings (IPR)
1 Nursing care plan with at least two nursing diagnoses
Weekly journaling, per instructor preference
Students MUST do Reflective Logs in evaluation packets
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Clinical Reflective Journal – Optional
Personal Journal:
Students will submit a daily journal to their clinical supervisor on the clinical day designated by the
clinical supervisor. A sheet of single paper or a non-spiral notebook may be used.
This is a tool designed for a personal inner journey rather than a reporting of what you have observed or
done. It is a journal of your thoughts and feelings about your clinical experiences.
This is confidential between your instructor and you and you may receive feedback. It is hoped that the
reflections and insight one develops as a result of the journal will foster personal and professional growth.
Suggestions for beginning journal:
1 – What was the high point of my day? Low point?
2 – Was I in disagreement with anyone? How did I handle it?
3 – What changes did I make in my thinking or behavior?
4 – How could I improve my day?
5 – What has been on my mind today?
6 – What are two choices I made today?
7 – What did I procrastinate on today?
8 – What feelings did I identify today?
9 – Say one positive thing about yourself for today.
10 – What happened to me was…………………..
11 – What this means to me is……………………
12 – For the first time I now understand………..
13 – I still question………………………………..
14 – Other
Journal Goals: Students are expected to submit 2 personal daily goals in their journal. Goals should be
evaluated in writing at the conclusion of the day prior to submitting the journal on the following day.
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Therapeutic Communication Definitions
Communication: Transaction between sender and receiver
Non-verbal: Physical appearance/dress, body movement & posture, touch, facial expressions,
eye movements, vocal cues
Therapeutic Communication Techniques
Silence: give time to collect thoughts, consider other concerns
Accepting: conveys attitude of reception and regard
Giving Recognition: acknowledge and indicate awareness (commend strengths)
Offering Self: making one’s self available on unconditional basis (increases self-worth)
Broad Openings: allows client initiative to introduce topic of concern (client role)
Offer General Leads: offers client the encouragement to continue
Placing the Event in Time or Sequence: clarifies event in time perspective
Making Observations: verbalizing what is observed or perceived (client behavior)
Encouraging Perception Description: ask client to verbalize what perceived-hallucination
Encourage Comparison: ask client to compare similarity and difference-reoccur/change
Restate: repeat main idea of what client said (client can clarify or continue on)
Reflect: questions and feelings referred back to client to recognize/accept own view
Focusing: taking notice of a single idea or word (don’t use if client is anxious)
Exploring: delve further into subject (helpful if client tends to be superficial in communication)
Seek Clarification/Validation: strive to explain the vague or incomprehensible
Present Reality: when client has misperception, nurse indicates perception of situation
Voicing Doubt: expressing uncertainty of reality of client’s perception (delusions)
Verbalizing the Implied: put into words what client has implied or said indirectly
Attempt to Translate Words into Feelings: find clues to feelings expressed indirectly
Formulate Plan of Action: when client has a plan of action for stressful situation, it may
prevent anger or anxiety form escalating into unmanageable level
Active Listening: sit facing client, open posture, lean forward, eye contact, relax
Feedback: descriptive of behavior, specific rather than general, directed toward what can be
changed, impart information not advice, well-timed (early after behavior)
Non-Therapeutic Communication Techniques (Blocks)
Giving reassurance
Rejecting
Giving approval/disapproval
Agreeing/disagreeing
Giving advice
Probing
Requesting an Explanation
Defending
Using Denial
Interpreting
Stereotype Comments
Indicating Existence of an External Power
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Belittling Feelings
Introducing an Unrelated Topic
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MENTAL STATUS EXAMINATION
The mental status examination is a process wherein a clinician systematically examines an
individual’s mental functioning. Each area of function is considered separately.
Appearance: This category covers the physical aspects of the individuals. Include: Physical
appearance, height and weight, how person is dressed and groomed, dominant
attitude during interview, such as degree of poise or comfort, degree of anxiety,
and how anxiety is expressed.
Behavior:
How does the person move and the position in which he/she holds body. Note
abnormal tics, movement disorders, and degree of movement.
Speech:
Separate speech from content of thought. Note volume, rate of flow of speech
(fast, slow, halting, extremely loud). Include mannerisms, accent, stress or lack of
it, hesitations, stuttering. Use descriptive words like garrulous, monotonous, loud
or emotional.
Mood/Affect: Affect is the outward show of emotion. Can vary thru depression, elation, anger,
and normality, but if the overall sense from the examination is depressed,
depressed is the word to describe the mood. Mood is the general pervasive
emotional state as reported by client. Range describes if the person shows a full or
even expanded range or if the affect is blunted or restricted. Include cultural
considerations. Consider appropriateness of affect – is the emotion consistent with
the topic being discussed. A client with inappropriate affect may cry when
talking about a parking ticket and show little or no emotion when discussing the
death of a loved one.
Thought:
Thought is divided into process, the way a person thinks, and content. What
he/she thinks.
Process:
The rate of thoughts, how they flow and are connected. A formal
thought disorder comprises processes such as pressured thoughts,
(excessively rapid), flight of ideas, thought blocking (speech is
halted), disconnected thoughts (loosening of association,
derailment), tangentiality, circumstantial thoughts (over inclusive
and slow to get to the point), word salad (nonsensical responses),
punning (talking in riddles), poverty of speech (limited content).
Content:
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Includes those things discussed in the interview and the person’s
beliefs. May have preoccupying thoughts – ideas of reference,
obsessions, ruminations or phobias. The person may have
delusions of control, thought insertion, broadcast, or delusions –
persecutory, grandiose, religious, reference, somatic, morbid
jealousy. For example, a depressed person may have delusions of
hopelessness, helplessness or worthlessness.
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Perceptions:
Covers sensory areas and describes distortions such as illusions, delusions or
hallucinations. Describe the nature of the experience in detail. Auditory
hallucinations (hearing voices) is more common in schizophrenics, visual
disturbances are more common in organic problems. In addition, there are
gustatory, olfactory, tactile, somatic, and kinesthetic hallucinations.
Depersonalization (the person feels unreal) are described here.
Ask “do you hear voices when no one else is around?” “Do you see things such
as ghosts, spirits, or angels?” Ask if the voices are commanding the person to do
anything, particularly homicidal or suicidal acts. Hallucinations can be in the form
of a running commentary. If the voices command a person to do something, does
the person obey the instructions or ignore them. Sometimes hallucinations are not
well-formed voices or objects – persons may hear bells ringing, knocking at the
door, banging sounds in his ears, or see vague things like halos or colors which
are difficult to describe.
Note how persons cope with the hallucinations and whether they are pleasant,
unpleasant or terrifying. Comment on the hallucinatory behavior, such as person
looking back repeatedly, gesturing or engaged in self-talk. To determine if the
person is having delusions, ask do you feel you have some special power or
abilities? Does the radio or TV give them special messages? Does the person
have thoughts that other people think are strange?
Obsessions and compulsions: Is the person afraid of dirt? Does he wash his
hands frequently or wash hands repeatedly.
Phobias: Does the person have any fear, such as animals, heights, snakes, crowds,
etc.
Preoccupations: Ask about ideas about the person’s body: He may believe he is
changing or has changed, that his elimination functions, sexual functions, or
digestive functions work in different or bizarre ways.
Cognition:
Look at areas of abstract thought which declines or is absent in a number of
conditions such as schizophrenia or dementia, level of general education and
intelligence, degree of concentration.
Consciousness: Level of conscious state is assessed, whether it is steady, fluctuating, cloudy, or
clear. Rate: 1=coma 2=stuporous 3=lethargic/evidence of drowsiness 4=alert.
Orientation:
Ask if the person knows the time and date, place, person (who he/she is), and the
situation the person is in.
Memory:
Memory is tested by looking for immediate recall. Give the client 3 unrelated
words (yellow, fox, Chicago) and ask him to repeat them. In 5 minutes ask the
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person to repeat them again. Do not tell the person that you will ask them to
repeat them in 5 minutes. (You need to write
them down so you remember.)
Recent recall: What did the person eat two meals ago?
Remote memory: When and where was the person born? Where did he go to
high school?
Confabulation: Filling in memory lapses by guessing or making up events.
Persons may do this if they cannot remember – if this occurs, just note it. You
might have to check information with outside sources for verification. You can
test for confabulation by asking if the person has seen you before – the person
who confabulates may fabricate details of a meeting which did not take place.
Concentration and Attention:
May be impaired for a variety of reasons: cognitive disorder, anxiety, depression,
internal stimuli. Ask the person to subtract 7 from 100 and keep subtracting 7
from the answer (serial 7s). Average time to complete is 90 seconds. Note the
person’s response to the task: irritability, frequent hesitation, or questioning. Four
or more errors is considered marginal; 7 or more indicates a poor performance. If
the person cannot begin the task, start at 50 and subtract 3s. If he is unable to do
that, have him count backward from 10. He is not to use paper to complete the
task.
Others:
Dreams: Are there dreams, how often, how vivid, any repetitive dreams,
nightmares? What is the content of dreams.
Déjà vu: Sensation of having been in situations similar to the present one.
Presence of suicidal/homicidal thoughts. Must inquire about specific plans,
suicide notes, impulse control. If positive, will he contract for safety?
Ask if person has any thoughts of wanting to hurt anyone, wishing someone was
dead? If yes, ask about specific plans.
Intellectual Functioning:
General knowledge: Who is the President, name 5 last presidents.
What is happening in the world? (war, economy). Name 5 major
US cities. If you go to McDonalds and buy 2 hamburgers for 70 cents
each and pay $2, how much change will you get back? Or, how much
is a quarter, dime, nickel and penny?
Math calculations: Ask basic math problems: 4+6 or 13-8.
Complex: Add 14+17.
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Ability to abstract:
Determine similarities
 How are an orange and a pear alike?
Good answer = fruit, Poor answer = round.
 How are a fly and a tree alike?
Good answer = alive, Poor answer = nothing
 How are a train and car alike?
Good answer = modes of transportation, Poor answer = they both have
wheels
Proverbs
 Ask “what does it mean to say: Don’t count your chickens before they are
hatched? Good answer = Don’t plan on future gains before they happen.
Poor answer = chickens are little.
Judgment and Insight:
Evaluate judgment with person’s response to: “What would you do if you were in
a crowded theatre and smelled smoke?”
“What would you do if you found an addressed, stamped envelope lying in the
street?”
Insight: How does the person perceive his present problem? “How did things
come to be this way?
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Mental Health Nursing Assessment
Student’s Name: __________________________________ Date: ____________________________
I.
Client Assessment
A. Client’s Demographic Data
Client’s initials: _____ Client’s Age: ____ Client location/room: ___________________
Admit date: ________ Gender: ________ Marital Status: _______ Children: ________
Career: ___________________ Last worked: ___________ Education: _____________
Cultural background: ________________________ Primary language: ______________
Spiritual belief/Religion: ___________________________________________________
Legal status: _____________ Privileges: _______________ Precautions: ____________
Living arrangements: ________________________ ADLs: _______________________
Family/community supports: ________________________________________________
Erikson’s developmental stage: ______________________________________________
B. DSM-IV-TR Admitting Diagnoses
Axis I- (Admitting psychiatric disorder(s)): ____________________________________
Axis II- (Personality disorder(s) or DD: _______________________________________
Axis III- (General medical diagnoses): ________________________________________
Axis IV- (Psychosocial/environmental factors): _________________________________
Axis V- (GAF Score):______________________________________________________
C. Psychopathology Leading to Current Admission
(Behavior, thought processes, dysfunction, crisis event, and past history or mental illness or
addictions)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
D. Contributing History or Events (i.e., social, cultural, family, etc.)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
E. Discharge Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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___________________________________________________________________________
___________________________________________________________________________
II.
Mental Status Exam Flow Sheet
A. Identifying Data
Client initials: ____________
Gender: _________________
Age: ____________________
Race/Culture: _____________
Occupation: _______________
Significant Other: __________
Living arrangements: ________________________
Religious preference: ________________________
Allergies: _________________________________
Special diet: _______________________________
Chief complaints: ___________________________
Medical diagnoses: __________________________
B. General Description
1. Appearance
Grooming/dress: _________________
Hygiene: _______________________
Posture: ________________________
Height/weight: ___________________
2. Motor activity
Tremors: ________________________
Tics/movements: __________________
Mannerisms: _____________________
Restlessness: _____________________
Aggressiveness: ___________________
3. Speech patterns
Slow or rapid pattern: _______________
Pressured speech: __________________
Intonation: _______________________
4. General attitude
Cooperative/uncooperative: ___________
Friendly/hostile/defensive: ____________
Hair color/texture: ______________
Scars/tattoos: __________________
Appears age?: __________________
Level of eye contact: ____________
Rigidity: ______________________
Gait: _________________________
Echopraxia: ___________________
Psychomotor retardation: _________
Range of motion: _______________
Volume: ______________________
Speech impediment: _____________
Aphasia: ______________________
Interest/apathy: _________________
Guarded/suspicious: _____________
C. Emotions
1. Mood
Sad: ___________ Depressed: _____________ Despairing: ____________________
Irritable: ________ Anxious: ______________ Elated: _______________________
Euphoric: _______ Fearful: _______________ Guilty: _______________________
Labile: __________
2. Affect
Congruence with mood: ____________________________________________________
Constricted or blunted: _____________________________________________________
Flat: ____________________________________________________________________
Appropriate or inappropriate: ________________________________________________
D. Thought Processes
1. Form of thought
Flight of ideas: __________________________ Associative looseness: ______________
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Circumstantiality: ________________________ Tangentiality: ____________________
Neologisms: ____________________________ Concrete thinking: ________________
Clang associations: _______________________ Word salad: _____________________
Perseveration: ___________________________ Able to concentrate: _______________
Echolalia: ______________________________ Mutism: _________________________
Poverty of Speech: _______________________ Attention span: ___________________
2. Content of thought
Delsusions: persecutory: __________ Grandiose: __________ Reference: _________
Control: _____________ Somatic: ____________ Nihilistic: _________
Suicidal/homicidal ideas: ___________________________________________________
Obsessions: _____________________________________________________________
Paranoia/suspiciousness: ___________________________________________________
Magical thinking: _________________________________________________________
Religiosity: ______________________________________________________________
Phobias: ________________________________________________________________
Poverty of content: ________________________________________________________
E. Perceptual Disturbances
Hallucinations:
Auditory: __________________ Visual: ____________________
Tactile: ____________________ Olfactory: _________________
Gustatory: __________________
Illusions:
Depersonalization: ________________________________________________________
Derealization: ____________________________________________________________
F. Sensory and Cognitive Ability
Level of alertness/consciousness
Orientation:
Time: ____________________________
Place: ____________________________
Person: ___________________________
Circumstances: _____________________
Memory:
Recent: _____________________________
Remote: ____________________________
Confabulation: _______________________
Capacity/abstract thought: ______________
G. Impulse Control
Ability to control impulses related to the following:
Aggression: ________________________ Guilt: ______________________________
Hostility: __________________________ Affection: ___________________________
Fear: ______________________________ Sexual feelings: ______________________
H. Judgment and Insight
Ability to solve problems
Ability to make decisions
Knowledge about self: awareness of limitations, awareness of consequences of actions,
awareness of illness
Adaptive/maladaptive use of coping strategies and ego defense mechanisms.
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Laboratory Data
Students MAY NOT use the term WNL or chart by exception on this form.
Write normal value range, exact value for patient, and indicate if this is normal, high, or low.
Sodium
White Blood Cells
Potassium
Red Blood Cells
Chloride
Hemoglobin
Glucose
Hematocrit
Blood Urea Nitrogen
Total Bilirubin
Creatinine
AST
Calcium
ALT
Magnesium
Alkaline Phosphatase
Phosphorous
Lithium/Depakote/Tegretol Level
Total Protein
TSH
Albumin
UA
Pre-Albumin
Drug Toxicology
Cortisol Level
What information can you obtain from these lab values? Why is this information important for this
specific patient?
Pathophysiology: Briefly summarize significant psychiatric/mental health problems, linking to
medical co-morbidities as applicable.
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Medication Preparation Log (MPL)
Student Name: _______________________________________
Clinical Rotation Date: ___________________________
Patient Identifier:
Diagnosis:
Code Status:
Relevant Medical/Surgical History:
Allergies:
Drug (Generic/Trade)
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Pt. Dose/
Normal Range
Route
Reason pt.
Frequency Classification receiving RX
Top 4 Side Effects
Nrsg Implications/
MUST KNOW
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Drug (Generic/Trade)
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Pt. Dose/
Normal Range
Route
Reason pt.
Frequency Classification receiving RX
Top 4 Side Effects
Nrsg Implications/
MUST KNOW
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Interaction Process Recording Instructions
The purpose of the Interactive Process Recording (IPR) is to demonstrate the student’s skills in understanding and
refining therapeutic interactions as part of the nurse-client relationship. The analysis of interactions with the patient
promotes the student’s ability to use the key therapeutic tool, the use of self, to facilitate growth in the nurse-client
relationship. The IPR assists the student to recognize personal feelings, actions and interactions throughout the
orientation, working, and termination phases of the relationship and to identify areas needing improvement.
Must have a minimum of 15 interchanges of interaction.
Instructions for Completing IPR Form
A. Cover Sheet
B. Dialogue/Analysis
1. Place all statements and nonverbal communications in the column under interaction. Statements
by the student and client are to be recorded verbatim – for example: “and then she just passed
away.”
2. Student analysis column
a. Enter the type of therapeutic technique used. “Silence” whether it was Therapeutic (T) or
Non-therapeutic (N).
b. Student rationale – to allow the patient more time to think about the death of his mother –
and your thoughts about the client’s response. He seemed close to tears and I felt
uncomfortable that I may have to see him cry. I did well not talking – I wanted to say
something like I felt sad when my grandmother died, but I didn’t – I allowed him the time
he needed to process his feelings.
c. Alternative statement (2) and for each (N) response.
3. Client analysis column
a. Analysis of client’s thoughts, feelings and response – possibly looking for approval from
student.
b. Anxiety level – rate none, mild, moderate, severe or panic. May also use 0, +1, +2, +3,
+4.
c. Labile defense mechanisms (2 required). If none, state none seen.
C. Evaluation Sheet
D. Basic Script for Opening
“Hello, I am a nursing student at ____________. I would like to talk with you for about 20 minutes
about some concerns or issues you may have which are related to the reasons you are here for
treatment.” When client agrees, say: “Anything we talk about is confidential.” If the patient is
unsure of where to start, use the following: “Tell me about the goals you are working on for your
treatment plan.”
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E. General Suggestions
1. Be direct in asking the patient to talk with you. Nurse counseling is a legitimate role and nurses
should be comfortable with it.
2. Utilize seating arrangement to facilitate the IPR.
3. Take a deep breath and set yourself before you start.
4. Use who, what, where, and when to follow up client statements as appropriate.
5. Avoid use of why and how statements.
6. Avoid jargon, euphemisms, slang and figures of speech, may be misunderstood.
7. Do not over-sympathize with the client about problems of living in the hospital.
8. Do not agree with “you know”. Clarify what they mean.
9. When the client uses psychiatric terms, ask what they mean by them.
10. Avoid close-ended questions.
11. Don’t get into the physical nursing role when counseling (i.e., “Do you need to lie down?”).
12. Do not tell the client how he should feel.
13. Do not use judgmental words like that was good, bad or great.
14. Don’t spend time discussing a client’s diagnosis.
15. Do not give advice.
16. If the client talks about things he would not do, ask what he would do or did.
17. Do not defend the staff or hospital.
18. Do not share personal information about yourself, students, or staff. Divert the questions by
saying “This is your time to talk about you.”
19. If your client is crying or emotional at the end of a session, stay with them. Ask if they are
feeling OK and do they have someone to talk to. Don’t just leave them.
20. Always report what client told you to staff before leaving the unit.
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IPR Cover Sheet
The purpose of the IPR is to provide you an analysis and critique of your communication knowledge and
skill. It also provides an opportunity to synthesize principles and concepts of the therapeutic relationship.
Use a 10-minute segment of your interaction and complete the following.
Student’s name: _____________________________________________
Date: ______________________________
Client: M or F
Age: _____________
DSM-IV-TR Diagnoses: ______________________________________
Ethnicity: _________________
Prologue: Describe where and when the interaction took place (environmental setting, emotional climate of
the milieu/setting, any significant client related data prior to the interaction and presence of others in the
area). DO NOT name the agency or unit. What was the presenting behavior of the client?
Phase of the relationship: (circle one)
Orientation
Student thoughts and feelings prior to interaction:
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Working
Termination
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IPR Analysis
Student Verbal
Communication
(Minimum 15
statements)
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Student
Non-Verbal
Communication
a. Identify communication
technique used. (T or NT)
b. Analysis of student
thoughts, feelings and
responses.
c. Alternative statements (2).
(i.e. What could I have said?)
Client Verbal
Communication
Client Non-Verbal
Communication
a. Analysis of client thoughts,
feelings and responses.
b. Anxiety level
c. Defense mechanisms if
present (2).
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IPR Analysis
Student Verbal
Communication
(Minimum 15
statements)
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Student
Non-Verbal
Communication
a. Identify communication
technique used. (T or NT)
b. Analysis of student
thoughts, feelings and
responses.
c. Alternative statements (2).
(i.e. What could I have said?)
Client Verbal
Communication
Client Non-Verbal
Communication
a. Analysis of client thoughts,
feelings and responses.
b. Anxiety level
c. Defense mechanisms if
present (2).
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IPR Evaluation
Evaluation of interaction goals. Were they met? If so, how? If not, why not?
A. Client-centered goal:
B. Student-centered goal:
2. Student’s communication pattern or style:
3. Student’s thoughts and feelings after the interaction:
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Scoring Rubric for MH IPR and Care Plan
Student Name:
Date:
Grade:
Below are the criteria that will be used to grade this assignment. A minimum grade of 78% for a rating of “pass” is required. Students receiving less that
78% must rewrite the assignment before the end of the clinical rotation. If second submission is scored less than 78%, the student will be referred to the Director
of Clinical Placement who will decide whether to uphold the failing grade or to recommend care plan remediation. Paperwork submitted late will be marked
down 5% for each day it is late.
1. Patient Profile Database Form
Assessment Portion of Profile
Includes subjective, objective, and
historical data as well as medical history
Pathophysiology
Briefly summarizes significant psychiatric/
mental health problems, linking to medical
co-morbidities as applicable.
Laboratory Data
Includes current lab results and their
significance for this patient
Medication Prep. Log
Properly completed including reason
taking medication, side effects and
important nursing implications.
10 pts
Above average
6 pts
Below average
4 pts
Unacceptable
< 50% of profile
100% of sections of profile
Pathophysiology of
Pathophysiology of
completed utilizing
subjective, objective, and
historical data.
Pathophysiology of primary
disease is accurate
Symptoms and/or comorbidities are correlated
Includes dynamic interactions
of medications & treatment
to disease process
All lab data is recorded
All labs are correlated to
patient’s medical condition
100% of medications are
listed with each area of log
completed appropriately
primary disease is
accurate
Symptoms and/or comorbidities are
correlated
75% of profile
completed utilizing
subjective, objective
and historical data.
primary disease is
accurate
Symptoms and/or comorbidities not
correlated
50% of profile
completed utilizing
subjective, objective
and historical data.
All lab data is
Lab data is recorded
Lab data not correlated
Score: _____ (Maximum Section Score = 20 points)
Revised
03.27.14
Comments:
8 pts
Average
recorded
Some labs are
correlated to
patient’s medical
condition
75% of medication
log completed
appropriately.
to patient’s medical
condition
50% of medication log
completed
appropriately
completed.
Student does not
display understanding of basic
pathophysiology
No lab data
recorded.
< 50% of
medication log
completed
appropriately.
Total
Score
26 of 31
10 pts
Above average
8 pts
Average
Assessment
Includes subjective, objective and
historical data that support actual or risk
for nursing diagnosis.
All pertinent data related
to nursing diagnosis
included
All pertinent data related to
Pertinent data related to
nursing diagnosis
Data unrelated to nursing
diagnosis included
Diagnoses
Includes 3 of the most appropriate
diagnoses for patient (2 medical; 1
psychosocial). NANDA-approved. Are
written in correct format: PES (for actual
diagnosis); PE (for potential or “at risk”
diagnosis); P (for wellness diagnosis)
Plan – Goal Statements
Includes 2 appropriate statements for each
nursing diagnosis which are patient
centered & written in SMART (specific,
measurable, attainable, realistic, &
time-specific) format.
Implementation – Interventions with
Rationale:
Includes three (3) interventions that
directly relate to each goal, are specific
(who, what, when, how much, how often)
and include a referenced rationale with
page number (s).
Evaluation:
Includes data that directly reflect goal
statements. State if goal has been met,
partially met, or not met. If goal was not
met or partially met, note whether plan of
care will be continued or modified and set
new date/time for evaluation.
Appropriate for
patient’s medical
condition
Supported by
assessment data
NANDA approved
Formatted correctly
100% of goal
statements fit the
nursing diagnoses
Patient centered
Written in SMART
format
3 interventions are
listed
Specific
Include a referenced
rationale with page
number (s)
Appropriate for patient’s
nursing diagnosis not
included
Data unrelated to nursing
diagnosis included
Not appropriate for patient’s
medical condition and/or
Not supported by assessment
data
Not NANDA approved and/or
formatted correctly
Contains data that
directly reflects goal
statements
Describes goal as met,
partially met, not
met.
If goal partially met or
not met, notes
whether POC will
be revised and set
new eval. date/time
2. Nursing Care Plan
Score: ______ (Maximum Section Score = 50 points)
Comments:
Revised 03.27.14
medical condition
Supported by assessment
data
NANDA approved
Not formatted correctly
75% of goal statements fit
the nursing diagnoses
Patient centered
Written in SMART format
6 pts
Below average
4 pts
Unacceptable
Assessment
section is
incomplete.
Diagnosis
portion is
incomplete.
50% of goal statements fit the
nursing diagnoses
May not be patient centered
and
May not be written in SMART
format
< 3 interventions are listed
Not congruent with goals
Not specific and/or do not
have a referenced rationale
< 50% of goal
statements
fit the
diagnoses
Contains data that directly
Does not contain data that
reflects goal statements
Does not describe goal as
met, partially met, or not
met
May also not include
revision or new
evaluation date/time
directly reflects goal
statements
May also not describe goal as
met, partially met, or not
met
May also not include revision
or new evaluation date/time
Evaluation
section is
incomplete.
3 interventions are listed
May not be specific
May not include a
referenced rationale with
page number (s)
Interventions
section is
incomplete.
Total
Score
27 of 31
10 pts
Above average
8 pts
Average
6 pts
Below average
4 pts
Unacceptable
All verbal and non-verbal communication
during the interaction noted (student and
client).
Utilized an equal
number of open- and
close-ended
questions 100% of
the time.
Zero use of “why” and
“how” questions.
Non-verbal
communication
techniques noted
Utilized an equal number of
open- and close-ended
questions 75% of the
time.
Minimal use of “why” and
“how” questions.
Non-verbal communication
techniques noted
Utilized an equal number
of open- and closeended questions 50%
of the time.
Frequent use of “why”
and “how” questions
and/or
Non-verbal
communication
techniques not noted
Student analysis: type of therapeutic
techniques (T or NT), student rational and
alternative responses to (N) techniques
noted.
100% complete
analysis of
therapeutic
techniques, rationale
and alternatives.
75% complete analysis of
therapeutic techniques,
rationale and alternatives.
50% complete analysis
of therapeutic
techniques, rationale
and alternatives.
Client analysis: analysis of client’s
thoughts, feelings and responses noted.
Client’s anxiety level and defense
mechanisms noted.
100% complete
analysis of client’s
thoughts, feelings
and responses.
Anxiety level noted.
Defense mechanisms
noted.
75% complete analysis of
client’s thoughts, feelings
and responses.
Anxiety level noted.
Defense mechanisms noted.
50% complete analysis
of client’s thoughts,
feelings and responses.
Anxiety level may not be
noted.
Defense mechanisms
may not be noted.
Utilized an equal
number of openand close-ended
questions < 50%
of the time.
Frequent use of
“why” and “how”
questions
Non-verbal
communication
techniques not
noted
< 50% complete
analysis of
therapeutic
techniques,
rationale and
alternatives.
< 50% complete
analysis of
client’s thoughts,
feelings and
responses.
Anxiety level not
noted.
Defense mechanisms
not noted.
3. IPR
Score: ______ (Maximum Section Score = 30 points)
Comments:
Section 1 Score
Section 2 Score
Section 3 Score
Deduction
Final Score
Revised 03.27.14
________
+ ________
+ ________
- ________ (if applicable)
= ________
Instructions: Add section scores together, and deduct for late paperwork,
if applicable. This will give you a Final Score. Then, refer to the Point
Conversion Table below to identify the student’s percentage points and
letter grade. Place the final letter grade in the identified location on page
one.
Total
Score
28 of 31
Point Conversion Table: 10 Graded Criteria (100 Maximum Points)
100
100%
Pass
95
95%
Pass
90
90%
Pass
85
85%
Pass
80
80%
Pass
78
78%
Pass
77
77%
Fail
75
75%
Fail
Revised 03.27.14
29 of 31
Nursing Care Plan Form
Student Name:
Date:
Patient Identifier:
Patient Mental Health/Medical Diagnosis:
Nursing Diagnosis
(use PES/PE
format):Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
1.
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; timespecific; and reasonable.)
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Rationale
(Provide reason why
intervention is
indicated/therapeutic; provide
references.)
Outcome Evaluation &
Replanning
(Was goal met? How would
you revise the plan of care
according the patient’s response
to current plan ?)
Statement #1
1.
1.
Outcome #1
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
3.
4.
Statement #2
Revised 03.27.14
Outcome #2
30 of 31
Nursing Care Plan Form
Student Name:
Date:
Patient Identifier:
Patient Mental Health/Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; timespecific; and reasonable.)
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Rationale
(Provide reason why
intervention is
indicated/therapeutic; provide
references.)
Outcome Evaluation &
Replanning
(Was goal met? How would
you revise the plan of care
according the patient’s response
to current plan ?)
1.
Statement #1
1.
1.
Outcome #1
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
3.
4.
Statement #2
Outcome #2
31 of 31
Nursing Care Plan Form
Student Name:
Date:
Patient Identifier:
Patient Mental Health/Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; timespecific; and reasonable.)
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Rationale
(Provide reason why
intervention is
indicated/therapeutic; provide
references.)
Outcome Evaluation &
Replanning
(Was goal met? How would
you revise the plan of care
according the patient’s response
to current plan ?)
1.
Statement #1
1.
1.
Outcome #1
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
3.
4.
Statement #2
Outcome #2