Mental Health Case: Li Na Chen, Part 1
Documentation Assignments
1. Document the search of Mrs. Chen and her belongings on admission.
Mrs. Chen was explained the reason for the search of her belongings in order to maintain safety for her
due to her suicide risk as well as for others. The items removed were a nail file, unwrapped tweezers, a
travel sewing kit, a decorative pill box, a personal cell phone, a belt, shoelaces, and a string from her
hoodie.
2. Document the safety checks for Day 1.
The scene was checked for safety and deemed appropriate because the nurse could get out of the room
if needed.
3. Document the findings of the mental status examination of Mrs. Chen on admission.
Mrs. Chen is appropriately dressed for age and weather. She is clean and well-kept other than her hair,
which is slightly disheveled. She has a slumped posture with no automatisms, such as tics, tremos,
akathisia, or restlessness. Her mood is sad and depressed and her affect is congruent with her thought
content. She does not have any indications of speech variations, like neologisms, aphasia, or pressured
speech. Her thought content involved worries, frustrations, hopelessness/helplessness. She denies
hallucinations. Thought process is goal-directed. She acknowledges self-harm or suicide urges as well as
acknowledging death wish without suicidal intent. She denies homicidal ideation. She is positive for
anhedonia. Mrs. Chen is orientated X3 with long-term memory deficits but a focused attention span. Her
insight is good.
4. Document the findings of the suicide assessment of Mrs. Chen.
Mrs. Chen stated, “ I cannot even do one thing right,” “I don‘t want help; I just want to get away from
this pain,” “I don’t think I can go on,” when asked if Mrs. Chen has any thoughts or wishes to harm or kill
herself.
5. Identify and document key nursing diagnoses for Mrs. Chen.
Risk for Suicide, Ineffective Coping, Helplessness
6. Referring to your feedback log, document all nursing care provided and Mrs. Chen’s response
to this care.
Feedback Log
0:00 You checked scene safety. It was correct to check scene safety in
order to maintain your own safety.
, 0:06 You introduced yourself.
0:37 You washed your hands.
1:20 You asked the patient: Is it OK for your husband to be here, while
we talk? It was correct to let the patient give her consent for
letting her husband be a part of the interview.
1:38 The patient said: Jack has always been there for me, and I have let
him down.\nYou answered: You have let him down? \nYou used
the therapeutic technique of restating.
2:12 You identified the patient.
2:28 You asked if the patient had any known allergies.
2:34 You made a safety check of the surroundings and the patient's
belongings.
3:37 You measured the blood pressure.
3:53 You checked the pulse oximetry.
4:11 You assessed the respiration.
4:22 You measured the temperature.
4:37 You checked the radial pulse.
6:13 You asked the patient: Have you had any changes in your appetite
over the past month? The patient said: I am not hungry.
6:36 You asked the patient: Tell me about any changes you have had in
your sleep over the past few weeks? The patient said: I sleep all
the time but never feel rested.
Documentation Assignments
1. Document the search of Mrs. Chen and her belongings on admission.
Mrs. Chen was explained the reason for the search of her belongings in order to maintain safety for her
due to her suicide risk as well as for others. The items removed were a nail file, unwrapped tweezers, a
travel sewing kit, a decorative pill box, a personal cell phone, a belt, shoelaces, and a string from her
hoodie.
2. Document the safety checks for Day 1.
The scene was checked for safety and deemed appropriate because the nurse could get out of the room
if needed.
3. Document the findings of the mental status examination of Mrs. Chen on admission.
Mrs. Chen is appropriately dressed for age and weather. She is clean and well-kept other than her hair,
which is slightly disheveled. She has a slumped posture with no automatisms, such as tics, tremos,
akathisia, or restlessness. Her mood is sad and depressed and her affect is congruent with her thought
content. She does not have any indications of speech variations, like neologisms, aphasia, or pressured
speech. Her thought content involved worries, frustrations, hopelessness/helplessness. She denies
hallucinations. Thought process is goal-directed. She acknowledges self-harm or suicide urges as well as
acknowledging death wish without suicidal intent. She denies homicidal ideation. She is positive for
anhedonia. Mrs. Chen is orientated X3 with long-term memory deficits but a focused attention span. Her
insight is good.
4. Document the findings of the suicide assessment of Mrs. Chen.
Mrs. Chen stated, “ I cannot even do one thing right,” “I don‘t want help; I just want to get away from
this pain,” “I don’t think I can go on,” when asked if Mrs. Chen has any thoughts or wishes to harm or kill
herself.
5. Identify and document key nursing diagnoses for Mrs. Chen.
Risk for Suicide, Ineffective Coping, Helplessness
6. Referring to your feedback log, document all nursing care provided and Mrs. Chen’s response
to this care.
Feedback Log
0:00 You checked scene safety. It was correct to check scene safety in
order to maintain your own safety.
, 0:06 You introduced yourself.
0:37 You washed your hands.
1:20 You asked the patient: Is it OK for your husband to be here, while
we talk? It was correct to let the patient give her consent for
letting her husband be a part of the interview.
1:38 The patient said: Jack has always been there for me, and I have let
him down.\nYou answered: You have let him down? \nYou used
the therapeutic technique of restating.
2:12 You identified the patient.
2:28 You asked if the patient had any known allergies.
2:34 You made a safety check of the surroundings and the patient's
belongings.
3:37 You measured the blood pressure.
3:53 You checked the pulse oximetry.
4:11 You assessed the respiration.
4:22 You measured the temperature.
4:37 You checked the radial pulse.
6:13 You asked the patient: Have you had any changes in your appetite
over the past month? The patient said: I am not hungry.
6:36 You asked the patient: Tell me about any changes you have had in
your sleep over the past few weeks? The patient said: I sleep all
the time but never feel rested.
