Concept Map as the Basis of Documentation Objectives
Concept Map as the Basis of Documentation 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
- Slides: 12