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