Writing a CarePath diagnosis
A CarePath diagnosis uses the problem, cause, evidence (PES) pattern.
Actual problem: Problem related to cause, as evidenced by signs and symptoms. Example: C1 Short-term pain, related to a surgical incision, as evidenced by a pain score of 7/10 and guarding.
Risk problem: Problem related to risk factors ; no signs of the problem are present yet. Example: S1 Likely to fall, related to weakness, a sleeping tablet, and past falls (risk factors).
Common mistakes to avoid
- Writing a medical diagnosis as the cause when a nursing cause is more useful for nursing action.
- Using a risk statement when the signs are already present. Choose the actual statement.
- Putting the treatment in the statement ("needs oxygen"). The statement names the problem; the plan names the treatment.
- Goals with no number or time ("pain improves"). Write "pain 3/10 or lower within 1 hour".
- Listing interventions in the order they came to mind. Put the most urgent first.
A good goal answers four questions: who (the patient), what change (behavior or measurement), how much (the target), by when (the time frame).