Nursing Care Plans Care plans are not a favorite among most nurses. It's difficult to develop plans for someone that is hospitalized, and you are unsure how things will go. However, as time consuming as they are, they are an essential part of nursing. The Need for a Care Plan Care plans are individualized plans specific to that patient. They are based on the exact needs of the patient, and it coordinates with the patient's diagnoses, and their specific needs. The care plan is designed to inform the following shift exactly what is being done for and with the patient. This is a way of communicating, similar to a log book passed on from staff to staff. Care Plan Contents In addition to the communication aspect of a care plan, it should provide instructions so that a nurse unfamiliar with the patient could step in and know what to do. This would include special request of family members or the patient themselves. Care Plan Guidelines Care plans must be completed for every patient that is hospitalized for more than 25 hours. Both Medicare and Medicaid require a care plan in a detailed format for every patient. If the care plan calls for a nurse with a specialty skill, then the patient will be assigned to a specific nurse for their expertise. Many insurance companies will deny payment if the care plan is not put in place with adequate notes and a summary of the patient's condition. There should be a nursing diagnosis included. A nursing diagnosis is not a medical diagnosis, but rather input from the nurse regarding the patient's spirit, mood, if they are eating well, etc. Related: More about Nursing Support Groups Care Plan Example (daily note) Mr. Blank was feeling fairly well this evening. He spoke of attending rehabilitation, therapy and did so with a positive outlook. Mr. Blank ate about half of his dinner, saying that he did not feel he could consume the rest. He later asks for a sandwich, and was able to eat that. The patient was reading and watched TV prior to going to bed. The patient was nauseous around midnight and received medication which seemed to help. Care plans benefit everyone that reads the patient's records. A social worker can read the care plan of a, patient, and gain quite a bit of information prior to even meeting them. That can help to develop potential
plan, and allow the social worker to explore options and present them to the patient. Care plans can also help to track the patient's progress and outlook. Close observation of a patient's care plan could indicate the need for counseling, as it can show levels of depression. Some care plans have graphs of charts that indicate the patient's mood, and this can help to determine if there are needs for additional supports. All patients have medical charts, which are filled with information that is all very detailed and specific. A medical chart or record will provide any information that is pertinent to the patient's health. Medical charts and notes are very accurate and complete, plus now that they are electronic, they are more helpful when a patient sees multiple doctors. There is no question, a medical chart is vital to the proper care of a patient. A Care Plan can serve as the more personal approach in some ways, it covers the patient's lifestyle. Before a chronically ill patient is released, it must be determined that they have a safe place to go, and that they can either care for themselves, or have others that can care for them. A care plan will provide input as to family involvement with the patient, and more importantly, how does the patient feel about being released, do they feel they are going to a safe environment. Related: Patient Hygiene A care plan is an essential part of a patient's records, and should be kept updated as much as medical records. If you are starting a care plan for a patient, be sure to spend some time with the patient, and actually get to know them before starting the care plan. Organize the care plan so that anyone could look at it, and learn information about the patient. A care plan benefits the patient, and all medical staff working with the patient. Related: Acclaimed Registered Nurse Michelle Hebert Dufrene, RN, MSN will be Noted in the Worldwide Leaders in Healthcare Please follow us on Facebook, Linkedin, Pinterest and Twitter