Concept Map as the Basis of Documentation

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Concept Map as the Basis of Documentation

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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

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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

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What is Documentation?

• It is the legal record of written communication
  of all patient care activities.
• -Individual client
• -Group of clients

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Purpose of Documentation

• To facilitate communication
• To promote good nursing care
• To meet professional and legal standards

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What to Documentation ?

• Everything on the map needs to
• be documentation somewhere!!

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ANA Standard of Care

• Standard 1 Assessment
• Standard 2 Diagnosis
• Standard 3 Outcome Identification
• Standard 4 Planning
• Standard 5 Implementation
• Standard 6 Evaluation

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Tool for Documentation

• Worksheets and kardexes
• Client care plans
• Flow sheets and checklists
• Care maps and clinical pathways
• Monitoring strips

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Documentation Method

• Focus charting
• Data, Action, Response
• SOAP charting
• Narrative charting

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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

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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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