Assessment and Care planning Documentation

The content on this site can be used by all health professionals particularly in the Ashburton and Rural Services and Medical Surgical Division of Christchurch Hospital. This site discusses the integration of assessment and care planning documents and provides approved screening tools and documents for use in assessment and care planning of patients/consumers.

Purpose of Integrated Assessment and Care planning documentation

  • To meet new Health Quality and Safety Commission recommendations

  • To standardise patient assessments and care planning in our hospitals to ensure we meet regulatory standards, while still accommodating speciality requirements e.g. patient and area specific section additions

  • To provide a user friendly process of assessment and planning by reducing the requirement to complete other forms that could be missed  i.e.

      • Smoking cessation pink form

      • Falls Risk Assessment and Management form

      • Pressure Area Risk assessment (Braden score form)

      • Family Violence Screening

      • Different Allied Health/speciality service referral forms (can be numerous speciality forms to complete)

  • To reduce the requirement for staff to record actions within the patients progress notes i.e. using our care planning documentation to its fullest

  • To ensure we can evaluate our assessment and care planning documents by using tick boxes for actions/interventions

 

​Use of documents - Process flowchartFlowchart.pdf

Education on Assessment and Care planning documents March 2015

Education points for Assessment and Care planning March 2015.pdf

Risk screening and Care planning Tools/Education​​Medical Surgical Division and Ashburton Hospital and Rural Services Screening tools and Flipchart Management Guide March 2015.pdf

Information on the use of Health Passports.pdf

Dementia and Delirium screening CAM and MSQ direction.pdf
Smoking-Cessation-Screening-Education


Mental-Health-Kessler-Screening-Tool-Education

Malnutrition-Screening-Tool-Education

Med Surg Divison forms - July 2012 changes explained​​

Patient-Admission-Questionnaire-July-2013

Med Surg and Ashburton Risk Screening and Assessment form Aug 2014.pdf

​​Med Surg and Ashburton Daily Care Plan July 2014.pdf

Care planning Guide for Med Surg form​

Med-Surg-Care-Planning-guide

Approved Abbreviations Vol A Christchurch Hospital (Note: This in an internal DHB document and can only be accessed when working inside the DHB computer network)​

ACC45 Pressure Injury Example
DIRECTIONS FOR OTHER ASSESSMENT FORMS
Directions on the completion of the  Use of Restraint form - Christchurch Hospital Campus​Use of Restraint Form - Education points for completion.pdf

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Page last reviewed: 30 August 2017
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