Comprehensive Patient Documentation Report: Mr. Leroy's ISBAR Analysis

This report presents a patient documentation of Mr. Leroy's case, focusing on an ISBAR (Identification, Situation, Background, Assessment, Recommendation) analysis. The report details Mr. Leroy's situation, including his unemployment, separation from his partner, and mental health challenges such as mood swings, anxiety, and medication non-compliance. His background includes a previous episode of mania and lack of follow-up care. The assessment indicates a manic disorder with symptoms like euphoria, flight of ideas, incoherent speech, restlessness, and tremors. The recommendations prioritize addressing disorganized thoughts, sleep disturbances, and neurological issues through interventions like over-the-counter sedatives, mindfulness meditation, health literacy, and anticholinergic medications. The report concludes that implementing these interventions can promote positive patient recovery. References to support the documentation are also included.

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

mania, the client did not attend any follow-up sessions for which his mental health seems to
have deteriorated.
A (Assessment): Upon assessing the client’s mental health status, it can be stated that the
client appears to suffer from manic disorder. The client experiences ‘euphoric’ mood and
‘flight of idea’. Further, the client speech is incoherent and repetitive and lacks proper syntax
or alignment. The client appears restless and is observed to experience tremors and also
position his hands on his head. The client also avoids eye contact to the maximum and
occasionally stares at the interviewer. However, it is important to note in this context that the
thought content of the client does not reveal information about harbouring suicidal thoughts
or experiencing any form of hallucinations or delusions. The client appears to be more than
his mentioned chronological age of 35 years and considers that he has not been able to sleep
or eat normally as he is extremely busy with his work schedule. The patient considers himself
brilliant in terms of business ideas and also believes that his symptoms have recovered to a
significant extent for which he does not need to consume medications.
R (Recommendations):
Three care priorities have been identified which include, disorganized thoughts and
flight of ideas, lack of sleep and neurological disturbance and tremors. For the same,
administration of over the counter sedatives, mindfulness mediation, administration of health
literacy and anticholinergic medications can help to acquire positive patient outcome. Also,
encouraging the patient to write down his thoughts and feelings can help to improve fleeting
ideas.
Conclusion:
Therefore, it can be expected that implementation of the recommended interventions
can promote positive recovery of the patient.

References:
Kanerva, A., Kivinen, T., & Lammintakanen, J. (2017). Collaborating with nurse leaders to
develop patient safety practices. Leadership in Health Services, 30(3), 249-262.
Kerr, D., Klim, S., Kelly, A. M., & McCann, T. (2016). Impact of a modified nursing
handover model for improving nursing care and documentation in the emergency
department: A pre‐and post‐implementation study. International journal of nursing
practice, 22(1), 89-97.