Concept Map as the Basis of Documentation 余 靜 雲余 靜 雲

Objectives List purposes of documentation Describe the relationships between the ANA standards of care, ANA documentation standard, and concept map care plan. Specify the basic content of nursing care documentation

Objectives Compare documentation formats for standardized forms and narrative progress notes Identify basis criteria that guide documentation Use the concept map care plan to identify content for documentation

What is “Documentation”? It is the legal record of written communication of all patient care activities. -Individual client -Group of clients

Purpose of Documentation To facilitate communication To promote good nursing care To meet professional and legal standards

What to Documentation ? Everything on the map needs to be documentation somewhere!!

ANA Standard of Care Standard 1: Assessment Standard 2: Diagnosis Standard 3: Outcome Identification Standard 4: Planning Standard 5: Implementation Standard 6: Evaluation

Tool for Documentation Worksheets and kardexes Client care plans Flow sheets and checklists Care maps and clinical pathways Monitoring strips

Documentation Method Focus charting Data, Action, Response “SOAP” charting Narrative charting

Documentation of Specific Problem For each nursing diagnosis, documentation can be done in three steps that are as easy as “ PIE”. Problem Intervention Evaluation patient responses

How to Documentation Accuracy Legibility Signature Correcting mistakes Logical organization of information Writing a late entry Completeness Omitted intervention Conciseness Note concerning other health-care providers

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