A patient enters the Practice Continuum with a medical diagnosis on admission to the hospital. 
Based on patient data and identified problems related to the diagnosis, a plan of care is formulated. 
The plan utilizes Patient Care Protocols and Treatment Procedures. It directs the patient toward 
the prescribed outcomes that will ready the patient for discharge. The plan of care is built on the fundamental principles of assessment, planning, implementation and evaluation. This process begins on admission with the systematic recording of the patient’s baseline data and history. The plan of care evolves from this point with the identification of patient problems/needs and the implementation of a clinical pathway or various protocols. It continues daily as biophysical assessments change, additional needs are identified, and corresponding protocols are implemented.

Charting is accomplished by using check marks, asterisks, or arrows on a standardized flow sheet. Narrative charting is required if the assessment or continuing care of the patient deviates from the predefined criteria.  Focus notes should be written to document critical value reporting: patient complaints, patient incidents and/or conversations with physician(s).

Biophysical assessments and routine patient care are documented on the 24-Hour Patient Flow 
Sheet at least every 12 hours. Planning is carried over each day as the night shift brings critical 
information forward by writing it on the 24-Hour Flow Sheet. Planning is also demonstrated through the 
methodical recording of interventions. Evaluation occurs with each deviation from the pre-determined 
standards and is documented with a focus note at the point of care. Evaluation also occurs as expected 
outcomes are met on the individual protocols. This is also documented by a focus note and/or discontinuation of the protocol.

Standards Based Documentation utilizes the following Patient (Data Recording) Forms:

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