Elaborate Patient Report 2022

Introduction:
This report intends to present an elaborate patient documentation of the case scenario
of the patient, Mr. Leroy. The report would critically present an ISBAR documentation of the
patient based on which the further assessments would be conducted and an appropriate
intervention plan would be devised for the patient. Also, the assessment would be considered
as the basis of nursing progress notes and accordingly further clinical decisions would be
undertaken by the concerned multidisciplinary care professionals.
Patient Documentation:
According to Kerr et al. (2016), patient documentation helps to critically present an
elaborate detailed assessment of the patient and based on the same the future course of
treatment intervention is planned. Appropriate patient documentation is extremely important
for accurate identification of patient care needs and holistic planning of effective healthcare
interventions (Kanerva, Kivinen & Lammintakanen, 2017).
I (Identification): The client, Leroy is 35 years old and is Caucasian in ethnic origin and has
attended the clinic at the request of his parents.
S (Situation): The client is unemployed and has separated from his partner, 6 months ago. At
present, the client stays with his parents. The client experiences severe mood swings from
being happy to behave in a threatening manner. Further, the client becomes anxious and has
stopped consuming his medication. On enquiring about his physical health problems, he
reveals that he experiences difficulty with optimal sleep and nutritional intake. He further
explains his agitation in relation to his busy schedule with his business idea.
B (Background): The patient had been treated 6 months ago at a local mental health clinic.
The reason for the treatment was mentioned as an episode of mania. Following the episode of