Plan of care ensures proper documentation.
Via Christi Regional Medical Center in Wichita, KS, uses a plan of care form to document patient care from pre-op to post-discharge, except for the intraoperative phase. The comprehensive form ensures good note-taking, even from traditionally poor documenters. A clinical pathway begins on page three of the form and covers tests, treatment monitoring, prescriptions, activity, discharge planning, nutrition, education, and consults for patients in partial day surgery, pre-op and post-op, holding area surgery, and the post anesthesia care unit. Potential problems areas for patients are documented in the following areas: comfort, skin integrity, communication, psychosocial, safety, mobility, physiological, and spiritual.
D019091:Critical Pathways; D004282:Documentation / Q000592:standards; D005568:Forms and Records Control / Q000592:standards*; D006801:Humans; D007615:Kansas; D010347:Patient Care Planning / Q000592:standards*; D019990:Perioperative Care / Q000592:standards*