Care Plans an Exercise in FUTILITY?????? - page 5

:uhoh21: I would like to know how many of you out there sit down and read each and every care plan on each and everyone of your residents each and every day before you start work? I am not talking... Read More

  1. by   Destinystar
    you hit the nail on the head ms. mercy. we need to find a way to make the care plan process work & for it to be utilized the way it was intended. :hatparty:
    Quote from missmercy
    care plans are supposed to assist nurses in providing consistant care for patients across shifts, days etc...... great idea in theory -- in practice, while they are nurse driven, independent from physicians orders and can provide specific , individualized road maps for patient care --they have become cumbersome, and often ignored. nurses are so busy doing the tasks that we have piled on top of us that the care plan issue feel like extras. in truth, care plans outline thing we can do without haveing to wait for a doctor to get back to us, things we do not have to wait for someone else to approve prior to initiating it! they have the potential to be a great source of evidence in favor of the professional role of the nurse. i think we need to find a way to streamline care plans as a whole -- they are time-consuming. many facilities have computer careplans that will spit out a form for the nurse based on what nsg, dx is entered -- that weems to trim some of the excess time --
  2. by   kids
    Quote from destinystar
    the care plan process is confusing to me. maybe you can clarify some issues since you have a lot of experience with them. in obra it is refered to as an interdisciplinary care plan. just states the rn must coordinate it that of course is a federal regulation. i dont know about your state but in california the state regulations (title 22) states that lvns are limited to writing whatever interventions they are responsible for on the care plan and only rn's can formulate nursing diagnoses. in spite of that it is common practice in the ltc in california for dietary supervisors, activity directors, & social service designees to be writing care plans. i mean nursing diagnoses, goals and interventions. lvn's write them to.
    the way the rules are in interpeted in my area is that the rns signature on the mds "certifies" that the contents are complete and accurate, the rn signature on the care plan "approves" it. the rules (here) do not specify that the rn writes every word on the mds/raps/care plan, only that an rn had reveiwed the contents, made any changes and approved it.

    i went thru to many state surveys before, during and after obra was implimented and 2 federal after using these methods, not once were they questioned. and yes, the state & federal surveyors were aware as it was the procedure was documented.
  3. by   Destinystar
    the ltc that i have worked in the surveyors have never commented on who wrote the care plan just on the accuracy of the information.
    Quote from kids-r-fun
    the way the rules are in interpeted in my area is that the rns signature on the mds "certifies" that the contents are complete and accurate, the rn signature on the care plan "approves" it. the rules (here) do not specify that the rn writes every word on the mds/raps/care plan, only that an rn had reveiwed the contents, made any changes and approved it.

    i went thru to many state surveys before, during and after obra was implimented and 2 federal after using these methods, not once were they questioned. and yes, the state & federal surveyors were aware as it was the procedure was documented.
  4. by   tshores
    I don't know much about LTC, but in ICU's I've worked in (for 25+ years), most nurses record patient-specific information in a kardex or sheet of paper (or even half-sheet of paper) left on a clipboard with the nurse's notes. That is our true care plan where we write all the diagnoses, history, lab to be drawn or other procedures, any tubes or drains to suction or not, dressings, whether to crush meds--anything at all pertaining to the care of that patient, even family phone numbers. Yeah, they get kinda messy with all the updates, but they're REAL care plans and that's what we really follow. I think we should just stick the messy old ones in the chart when we make out new ones because that's what we really do for our patients.
    But instead, we have a four-page NCP no one looks at (at least not for any guidance), a two-page teaching form, and a three-page admission form. Yes, we need an admission form, but we sure don't need the other forms. We should be charting our teaching anyway without a separate form. And now we have wound assessment forms and orders, restraint forms and orders, epidural forms, PCA forms, transfusion report forms, and so on. If we give blood to someone who has a PCA, we are charting VS on three different papers (including the nurse's notes). Ridiculous. I agree that NCP's are great for students, but they're an incredulous waste of time for nurses. Let's start saving our real care plans (you know, the messy but true ones) and save a lot of trees, too.
  5. by   alacek
    We utilize clinical pathways, and they are located on the opposite side of our nurses note (flowsheet). I work in OB, so most of our patients have a fairly identical and straight forward POC. There is room at the bottom to add in anything unique to each patient. I actually review mine every day, mainly because I don't work on the postpartum side very often, and I need to refresh my memory on what needs to be done. In L&D, we don't use the clinical pathways
  6. by   Destinystar
    I agree in the olden days the care plan was a very functional tool to pass info from shift to shift, it was written in pencil and updated with the essentials every shift for continuity of care. In LTC they have taken it to another level. It has turned into a nursing manual. Not user friendly. Put in the charts because that is what the law mandates, It is way to much information for anyone to find any practicle use for them.
    Quote from tshores
    I don't know much about LTC, but in ICU's I've worked in (for 25+ years), most nurses record patient-specific information in a kardex or sheet of paper (or even half-sheet of paper) left on a clipboard with the nurse's notes. That is our true care plan where we write all the diagnoses, history, lab to be drawn or other procedures, any tubes or drains to suction or not, dressings, whether to crush meds--anything at all pertaining to the care of that patient, even family phone numbers. Yeah, they get kinda messy with all the updates, but they're REAL care plans and that's what we really follow. I think we should just stick the messy old ones in the chart when we make out new ones because that's what we really do for our patients.
    But instead, we have a four-page NCP no one looks at (at least not for any guidance), a two-page teaching form, and a three-page admission form. Yes, we need an admission form, but we sure don't need the other forms. We should be charting our teaching anyway without a separate form. And now we have wound assessment forms and orders, restraint forms and orders, epidural forms, PCA forms, transfusion report forms, and so on. If we give blood to someone who has a PCA, we are charting VS on three different papers (including the nurse's notes). Ridiculous. I agree that NCP's are great for students, but they're an incredulous waste of time for nurses. Let's start saving our real care plans (you know, the messy but true ones) and save a lot of trees, too.
  7. by   Destinystar
    My post was geared towards LTC and the way they are used in that setting. IN LTC a nurse can easily have 60 patients. The care plans in LTC are written and utilized differently than they are in a hospital. We have elderly people with ADL defecits and several medical problems, CHF, Diabetes, Stroke, Shizophrenic, etc. The care plans for these folks look like a novel. On the other hand in your setting you are responsbible for like 2 or 4 patients that have similar problems with a few extra things here and there. And I am sure with this few you have the time to review, update and read the care plans every shift. On 60 residents with as many as 25 different problems we dont have time to review the care plans.
    Quote from alacek
    We utilize clinical pathways, and they are located on the opposite side of our nurses note (flowsheet). I work in OB, so most of our patients have a fairly identical and straight forward POC. There is room at the bottom to add in anything unique to each patient. I actually review mine every day, mainly because I don't work on the postpartum side very often, and I need to refresh my memory on what needs to be done. In L&D, we don't use the clinical pathways
  8. by   bluesky
    Quote from Brickman
    But without careplans we wouldn't have anyplace to write the ever so helpful nursing diagnoses.


    :chuckle
  9. by   alacek
    Quote from Destinystar
    My post was geared towards LTC and the way they are used in that setting. IN LTC a nurse can easily have 60 patients. The care plans in LTC are written and utilized differently than they are in a hospital. We have elderly people with ADL defecits and several medical problems, CHF, Diabetes, Stroke, Shizophrenic, etc. The care plans for these folks look like a novel. On the other hand in your setting you are responsbible for like 2 or 4 patients that have similar problems with a few extra things here and there. And I am sure with this few you have the time to review, update and read the care plans every shift. On 60 residents with as many as 25 different problems we dont have time to review the care plans.
    Absolutely the difference! Although, I usually have more than 2-4 patients. Well, in L&D, that is about right, but we chart on our patients on average of every 15 minutes, so it is pretty busy. In PP, we sometimes have up to 10 couplets, so this can be very busy, and I find that reviewing the clinical pathways really helps me better care for the patients. As for LTC, I will give it to you guys, because I could never do that type of nursing. Actually, I think I could, but I would not enjoy it. I did home health for a few years, and the paperwork was awful, so I can imagine in LTC. Good Luck!
  10. by   Destinystar
    i did ltc nursing for 27 years and didnt enjoy it. couldnt do it anymore. would not recommend it. when it comes to ltc nursing takes on a whole new meaning.
    Quote from alacek
    absolutely the difference! although, i usually have more than 2-4 patients. well, in l&d, that is about right, but we chart on our patients on average of every 15 minutes, so it is pretty busy. in pp, we sometimes have up to 10 couplets, so this can be very busy, and i find that reviewing the clinical pathways really helps me better care for the patients. as for ltc, i will give it to you guys, because i could never do that type of nursing. actually, i think i could, but i would not enjoy it. i did home health for a few years, and the paperwork was awful, so i can imagine in ltc. good luck!
  11. by   missmercy
    We use careplans, kardex and are looking into clinical pathways as well. Our house policy states that we must have 3+ pertinent care plans on each patientand they must be updated at least daily! Your idea of using the Kardex isn't bad -- ours would need some tweaking -- am not sure if it covers all the legalizms etc.......... Of course, the Kardex would have to remain multidisciplanary, but a section of it could be purely nursing care plans!!

    HMMM!
  12. by   AMICRW
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    care plans are used in our facility as well as "care cards" so that all have a brief of what the care plan requires and shows any changes. all caretakers, then, know what is the actual current expectation. in fact, each caregiveer is accountable for any thing done that goes against what is on the care plan / cards. when litigation has happened, and care was being given according to the care plan, it is easier to show that it was a suddden change in the patient's condition, which does influence the outcome.
  13. by   kateRN
    Care plans are meaningless wastes of time. They don't mean anything, and their only purpose is to generate more points when JCAHO comes.
    I fill mine out everyday because we're supposed to, but they don't influence my nursing care at all. Especially because most of them have information about prescribing meds in them. I'm not going to say to the docs, "excuse me? as you can see here on the care plan, it is day #3 on the 'acute coronary syndrome pathway' and this patient is not on an ace inhibitor. don't you think they need to be on one?" They would look at me like I had three heads. Patients would get much better care if nurses didn't have to spend hours doing worthless paperwork.

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