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

討 論