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Concept Map as the Basis of Documentation

Learn how to use concept maps to guide nursing care documentation and understand the relationships between ANA standards, documentation standards, and concept map care plans.

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Concept Map as the Basis of Documentation

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  1. Concept Map as the Basis of Documentation 余 靜 雲

  2. 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

  3. 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

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

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

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

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

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

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

  10. 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

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

  12. 討 論

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