Found the information at work, after careful searching! Just FYI, in case anybody is interested.
1. Document on Nurse’s Notes form.
2. Address each Care Plan problem and its components on a rotational basis each month, using DAP format.
3. Data, Assessment, and Plan (DAP) Documentation:
Each narrative nursing note entry that addresses either a Care-Plan problem or Clinical Situation will be documented by:
A. Writing the Date, time of entry, and name of Care-Plan problem/Clinical situation.
D: Data - 01/01/01 – 1000 – Painful L heel.
Enter all pertinent subjective and objective information that is gathered. Data collection includes the nursing history, physical examination, laboratory data and diagnostic tests, and information from health team members, the resident’s family and significant others.
A: Assessing – Signs and symptoms of pressure areas.
This is the analysis, logical examination of, and professional judgment about assessment data used in the diagnostic process of forming an opinion.
P: Planning – Inform MD of change of skin integrity. monitor skin and pressure areas, and care for skin per MD orders.
Enter what you plan to do about the problem, based upon your assessment.
The only time to use terms such as “problem continues: no changes made” is if all areas of the care plan problem remain current.
In that case, add the word “because” to your statement.
Example: “The care plan will continue without change because the cognitive function will not improve above present status.”
4. This is the time to make ANY care-plan additions/adjustments. Do not wait for a staffing date.
5. Sign and title closure of entry.