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We just had a mock survey, and the surveyor pointed out our (electronic) care plans were not always pertinent to the diagnosis, had not been updated, or closed out when no longer a "problem".
But I think there's a reason that the nurses don't place a high value on care plans, and why they're seen as "busy work" Nurses sometimes feel they don't really add value to their patient care.
What do you think? Thanks!
I use and document on care plans, I helped develop them for our EPIC
maternal child. I will tell you that the two times I went to court, nursing care plans were on the big screen for all to see.
At at least hit the met ongoing button and make a quick blip for the not met.
Care plans are overused in LTC. Our care plans are updated regularly and some care plans are 8 pages. We have certain elements that must be present for the auditors.
In theory, care plans are valuable. However, I am certain my staff are not reviewing 8 pages. They don't have time, and it's the same for most facilities.
I agree with both sides. It does feel like busy work, especially when you've got more 'essential' tasks to do. However, as NicuGal and GrnTea point out, there are legal ramifications for not charting.
I think of the universally applied "Fall Prevention" goal in Epic. Obviously as a competent nurse, you're going to take action to prevent falls every shift. Simply charting 'Fall precautions in place, pt remains free of falls' lets you take credit for what you're already doing; if you didn't chart it, you didn't do it. And yes, it is pain in the butt and takes extra time when you're busy. (COBs, please feel free to start flinging bat guano in this pushy youngster's direction...)
My former hospital apparently got their butt handed to the by the JC because nurses weren't consistently charting on care plans. Now they have to at least hit 'acknowledge' q shift.
The only place that I've heard it's incredibly helpful is rehab. Allows the nurses to be on the same page re. progress toward meeting specific, personalized patient goals.
Yes we do chart in the plan of care section because it is required, not because it helps patient outcomes. In ICU, it is understood that everyone is a fall risk, we do mouth care, and reposition everyone every 2 hours as a matter of course. It is right there in my documentation.
I consider the real "plan of care" to be when the doctors, nurse and respiratory therapist meet together on rounds to discuss the plan for the day and the future.
Do you work at my hospital? Our mock survey said the exact same things and all of the nurses basically said its busy work. You don't need a care plan to know its part of your nursing duty to allow an anxious patient periods to ask questions or to allow a patient who is feeling isolated time spent with visitors, etc.
I agree that care plans are useless in the real world as actual plans of care. I always chart in them every shift anyway, and chart about things I actually did, just to cover my butt.
The only reason care plans are useful is they are good physician communication tools. I don't know how it is with you guys, but physicians don't read our assessments. However, where I work, they clearly do read the progress notes, which is where what I put in my care plan shows up. I have read consult notes from physicians the next day that specifically read, "wound is healing well per nursing notes" and things of that nature after I have charted on a wound's appearance under the skin integrity care plan. So, if there is something I think a physician should know, like an assessment finding that is NOT critical and will gain me a new hole on my body to defecate out of should I call a physician about it at 0300, I will make sure to write about it in the care plan. Maybe not all physicians read them, but clearly some physicians do.
I believe Nursing school "care plans" don't make much sense. When I had to do them content wasn't near as important as # of pages. The more pages you had the better your care plan (10 page care plan, poor-50 page care plan excellent- didn't make much sense then, doesn't make much sense now. I found you could take a majority of the nursing diagnosis and care plans and use them for all patients- risk for fall, fve or fvd, risk for infection, risk for impaired body image etc....
On the other hand a specific plan of care can be an important part of a pt's education and follow-up. NANDA and the verbiage to dance all around medical diagnosis to come up with nursing diagnosis has gone by the wayside in my opinion. If a patient has diabetes then the plan of care should be specific to diabetes( a medical diagnosis) and specific for that patient.
If it's anything like the nursing dx. I see students posting here, no, it's not concise.
If I spend any more than 2 seconds thinking about a "care plan", then I'm quite honestly wasting my time. Care plans in acute care do not drive the care that I give. My critical thinking and clinical expertise is what drives my patient care. For example, if my patient is at risk for inadequate tissue perfusion (according to NANDA), do you honestly think I'm going to stop and check my care plan to see what I should do?
I hear you, and I am sorry that I have been unclear in making my point.
Students have to put a lot more into their plans of care for school purposes precisely because they do not know much, and part of the exercise is to teach them about what certain patients can be anticipated to need, and how to assess for those many possibilities. So no, a working plan of care (medical, nursing, physical therapy, dietary, or any other professional service's plan of care) will not be that wordy.
However, the other thing to remember is that students have their hands full enough with thinking about what they would do and don't even think about delegation or the fact that somebody else may be following their plan of care, in the same way that a covering physician would follow a medical plan of care (assuming no new assessments reveal new diagnoses) or the PTs and PT aides would follow the lead PT plan of care. This is where my comment about charting and legal audits come in.
According to law and regulation, the plan of nursing care must be developed by a registered nurse based on an assessment. This doesn't just mean your plan of care based on your assessment this minute or at the beginning of your shift and ceasing at the end of it, it means for the patient's entire stay and recognizes the idea that care may be delegated to LPNs or CNAs.
I have seen charts where Nurse A did a bang-up job of assessing and implementing an appropriate plan of nursing care, and then she's off for two days, during which time the patient was cared for by others who weren't nearly as good. Good care got missed, bad things happened, and the hospital gets slammed with a lawsuit for not providing continuity of care and missing later developments ... and there's no documentation that Nurse A's plan of care was ever seen, much less adhered to, by the nursing staff in the patient's unit, or that as a whole, the hospital department of nursing thought it was important to do much of anything regarding planning nursing care for its patients except winging it from shift to shift. Especially problematic with 12-hour shifts where there's rarely more than 2 days in a row of seeing the same RN, temps, and travelers.
So of course the experienced nurse doesn't need to look at a plan of care for, say, somebody with difficulty breathing to know what to do. But suppose she (or you!) identify some significant problem for this patient that has nothing to do with the expected sorts of things for his general admitting diagnosis. Then what? If you don't put it in the plan of care, what will happen if the next shift or the next few days doesn't see what you see because they don't look for it, or do what you did because they had no clue?
You see the difficulty. Nurses have a lot more power than they take to their hearts; assessing and planning and being accountable for following a consistent plan of care is so critical for patients that it's in the law that we do this. Do you really think that if everybody said, "Well, I don't want to waste any time writing a plan of care for nursing this patient while he's here, because I know what to do," that things would go well? What if your physical therapist did that, and there was no plan that every therapist and therapy aide agreed on for your postop hip replacement-- a different person comes in every shift and just does what s/he thinks is best? Or if there were no medical plan of care, and we sorta drift along doing whatever pops into the head of the hospitalist or coverage of the day? No, there's a PLAN.
Now maybe your place has really good clinical roadmaps with allowances for making exceptions for specific off-the-edge assessment findings. Great. Those are plans of care and usually incorporate medical, nursing, and other specialty plans into a cohesive whole. If you don't have those, then you are reactive rather than proactive, and you have to think that perhaps somebody who follows you will not see what you see or look for what you think they should look for or do what you think should be done. Do you see the difference?
I think in most cases care plans are one of the biggest waste of time there is and are useless. No one usually looks at them
SierraBravo
547 Posts
I acknowledge the care plan in Epic because it is required. So that takes me about 2 seconds. If I spend any more than 2 seconds thinking about a "care plan", then I'm quite honestly wasting my time. Care plans in acute care do not drive the care that I give. My critical thinking and clinical expertise is what drives my patient care. For example, if my patient is at risk for inadequate tissue perfusion (according to NANDA), do you honestly think I'm going to stop and check my care plan to see what I should do?