DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

COLLEGE OF NURSING

NURSES PROGRESS NOTES

PATIENT NAME: AGE SEX ROOM/WARD HOSPITAL

Last Name First Name M.I. 36 (/) M Psychiatric NO.
J.R. () F

DATE/TIME FOCUS DATA/ACTION/RESPONSE

05/04/2022 Initial Assessment D: Arrived at the psychiatric clinic, a 36-year-old male, wearing
@ 10:00 am bright colored clothes, well- groomed and has a mesomorph
body type. He is active, aware of his surroundings, restless and
acts in an overly confident manner with exaggerated body
language and fast-paced speech.

A: Instructed to sit on the designated chair. Established rapport

and encouraged verbalization of feelings and concerns.

11: 30 am Impaired Social D: “I can’t talk to my family, they all think I don’t know better” as
Interaction verbalized. Has a habit of frequently interrupting conversation,
likes to blame and make obscene remarks about others, uses
incomprehensible rapid, forced speech pattern, demonstrates
flamboyant, excessive gregarious behavior and has a religious
grandiosity.

A: Established limits on interruptive behavior. Explored and

identified escalating behaviors. Redirected negative behavior
and emotions in a calm, firm, and non-defensive manner such
as take a walk, physical activity, or quiet time. Continued to
listen, monitor, and respond to verbal expressions and social
behaviors. Encouraged in gradually interacting with others and
praise for attempting and using socially appropriate behaviors
such as “you spoke to me more appropriately today.”. Included
the family as appropriate in those aspects of the client’s
treatment plan.

R: Consistently demonstrates habit of interrupting

conversation, still likes to blame and make obscene remarks
about others, incomprehensible rapid, forced speech pattern is
still apparent throughout the conversation, maintains
flamboyant, excessive gregarious behavior with his belief of
religious grandiosity.

RLE - NCM 109 Sample Only