Do you have to make care plans once you are a working nurse?

  1. Just curious. I see posts about help with careplans for nursing school assignments, but do you have to do the careplans once you are an LVN or RN?
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  2. 16 Comments

  3. by   Pompom
    Yes, but they are much less detailed than school assignments and most are computerized which makes it easy. Personally, no nurse I know even looks at them, it is justa JACHAO thing.
  4. by   S.T.A.C.E.Y
    I've never seen nurses do them in the hospital we have clinicals at. We were told doing careplans in school is simply to get your mind thinking in the right direction. You should be able to do them in your head (for the most part) once you are a nurse.

    The only place I've ever seen them is in the psych hospital.
  5. by   SOREFEETEMPTYSTOMACH
    Yes You Do But After Several Years Of Working It Comes Naturally. I Worked In E.r. So We Really Didn't Have To Sit Down And Write Care Plans Like The Floors Did But Most Of Us Seasoned Nurses Had It In Our Brains.in Fact That May Be The Most Difficult Part Of Orienting To The Department.
  6. by   NYNewGrad
    not on our floor.
    Theoretically, somehow its incorporated into our focus notes - in reality the answer is no.
  7. by   AuntieRN
    We do them but they are computerized so all you do is go in and take out what you don't want in there. For example: pt has fx hip: you click on the fx hip and it all comes up for you then you kinda tweek it towards that particular pt. I feel for ya I remember doing them in school and they were awful.
  8. by   PMFB-RN
    Quote from jlhalloween
    Just curious. I see posts about help with careplans for nursing school assignments, but do you have to do the careplans once you are an LVN or RN?
    *** YES! Well I don't actually write care plans, our's are all pre-printed but a nurse must create a plan of care for that patient for that shift. After a while you don't even think about it, it just comes natural.
  9. by   Daytonite
    I am citing a section from federal law, Title 42 Public Health, Conditions of Participation for Hospitals. This regards participation in Medicare. Nearly all acute hospitals take on Medicare patients, so they must follow these laws, particularly this one:

    Title 42 Code of Federal Regulations Sec. 482.23 (b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

    So, the answer to your question is: Yes

    Please understand that writing care plans is a skill no different from putting an IV or a foley catheter into someone. It is no different from learning to tie one's shoe laces. The difference is in the level of difficulty. It requires practice, practice, practice. Nurses are only human. We humans tend to gladly do those things that we are good at. Many of us will shy away from and even avoid those things that are hard or we never mastered to begin with. Much of this depends on your basic character. Are you one to run away from challenges? Or, do you meet them head on? It took me many years to become proficient in starting IVs and writing care plans--two of the harder nursing skills. Letting them triumph over me wasn't an option I was willing to tolerate. How about you?
  10. by   WDWpixieRN
    I'm only a first-semester student at this point, but if you haven't bought some care plan books to reference, I would highly recommend you do so.

    They make the whole process so much easier -- as our instructor told us, we're not reinventing the wheel here!!
  11. by   UKRNinUSA
    I work in the ER -we have check box care plans to satisfy the legal requirements but I agree with the previous posters that say that the real care planning is unwritten and a mental process. Written care plans are useful for communication between multiple caregivers and to train your brain in the problem-solving process, so don't join the naysayers that believe they are a waste of time -they're not.
  12. by   Pompom
    When we do our 24 hr. chart checks we also update the interdiciplinary plan of care, as we call them, basically it is just a few computer clicks that nothing has changed or the problem has resolved. This is just a nuisance thing and not really looked at by nurses. As I said before I believe this to be a JACHO thing not a reality in nursing thing.
  13. by   cardiacRN2006
    YES!
    I have to write out the RN diagnosis, the interventions, the goal, and if the goal was met or not and why. If they have a psych Dx or were ever in restraints, I have to include those as well.

    It's only 1 page, but it is a care plan no less.
  14. by   suznan
    In the hospital where I do clinicals they have preprinted care plans for everything. At the end of the shift we have to go over them and sign off on things that have been done ie education, and any goals that have been met. Susan

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