Are care plans valuable?

[Nurse Beth]

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!

[Dogen]

I am still struggling with double-charting because of what people actually look at. They look at the notes, not the flowsheets. Also, it seems that surveyors want to see care plan documentation in the notes, and don't give a whit that I've ticked off interventions related to the care plan in the flowsheets. The surveyors, therefore, aren't seeing the forest for the trees.

I don't know, I was reading an article a while back that said when reviewing access records in an EMR, only 20% of nurses' notes were read by a physician, and 38% of nurses' notes were never read by anyone but the nurse that wrote it. Can I ask how you know people are reading your notes? I write really good notes (IMNSHO, but I also read notes), but I assume no one reads them mostly because I never see anyone looking at nurses notes when I'm at work.

[dudette10, MSN, RN]

I don't know, I was reading an article a while back that said when reviewing access records in an EMR, only 20% of nurses' notes were read by a physician, and 38% of nurses' notes were never read by anyone but the nurse that wrote it. Can I ask how you know people are reading your notes? I write really good notes (IMNSHO, but I also read notes), but I assume no one reads them mostly because I never see anyone looking at nurses notes when I'm at work.

Many of the docs will include in their notes exactly what was said in the nursing notes, or they will say, "yeah, I saw that in your note." At least they do with mine. Some nursing notes are all CYA and not developed to actually communicate with other members of the team. I make sure that mine are written to communicate and to CYA.

ETA: what I mean by "to communicate." If there is an order to wean off O2 or an order to d/c a Foley that was put in for urinary retention or the MD notes show concern for nutrition or a post-surg patient has had a history of being reluctant to ambulated or a patient hasn't pooped in three days, I address my interventions and outcomes specifically. "Order to wean off O2 in anticipation of discharge tomorrow acknowledged, reduced LPM to 3L NC @ 1745, recheck of SPO2 at 1815 was 95%, no tachypnea, no significant change in HR, pt denied SOB. Will endorse continued weaning to noc nurse." I also make sure I do endorse the weaning to the noc nurse. If I have time after report, I will update my note to past tense.

[dudette10, MSN, RN]

I don't know, I was reading an article a while back that said when reviewing access records in an EMR, only 20% of nurses' notes were read by a physician, and 38% of nurses' notes were never read by anyone but the nurse that wrote it. Can I ask how you know people are reading your notes? I write really good notes (IMNSHO, but I also read notes), but I assume no one reads them mostly because I never see anyone looking at nurses notes when I'm at work.

Good notes will be read more often than just CYA notes. Just as we as nurses know the interns, they know us. If you consistently write good notes--i.e. Informative ones to providers and other HCWs-- they will be read.

[Dogen]

Many of the docs will include in their notes exactly what was said in the nursing notes, or they will say, "yeah, I saw that in your note." At least they do with mine. Some nursing notes are all CYA and not developed to actually communicate with other members of the team. I make sure that mine are written to communicate and to CYA.

ETA: what I mean by "to communicate." If there is an order to wean off O2 or an order to d/c a Foley that was put in for urinary retention or the MD notes show concern for nutrition or a post-surg patient has had a history of being reluctant to ambulated or a patient hasn't pooped in three days, I address my interventions and outcomes specifically. "Order to wean off O2 in anticipation of discharge tomorrow acknowledged, reduced LPM to 3L NC @ 1745, recheck of SPO2 at 1815 was 95%, no tachypnea, no significant change in HR, pt denied SOB. Will endorse continued weaning to noc nurse." I also make sure I do endorse the weaning to the noc nurse. If I have time after report, I will update my note to past tense.

The article I cited is only one academic medical center, so I don't know how representative it is, but as a nurse who never sees nurses reading nursing notes (at least, whoever happens to be sitting next to me at the nurse's station every shift), and as an NP student who finds them frequently devoid of useful information, it wouldn't surprise me if it were common everywhere. I'd like to think someone reads my notes - if I knew no one was I'd write them twice as fast.

I like what you wrote, but it's not very typical of what I read in nursing notes. Usually what I see is things like "PRN Risperdal minimally effective," which means virtually nothing. Or, "Pt ambulated in the hall, no dyspnea, O2 > 90%," but they don't say how far they were ambulated.

Patient education is another one... I love education as an RN. I love doing it, and I think it's important, and I'm glad it's part of my job. As an NP student, though, a note that talks about the various topics a patient was educated on tells me nothing diagnostic, so it doesn't help me to help the patient. I'm sure someone can come up with a scenario where education saved a patient's life, which is why I love doing it, but that doesn't make it helpful for me to read about in a note.

I also find that nursing diagnoses are often so vague that they don't tell me anything. I know some people here are big on them, and it's totally possible that I've never seen a good one done, but I frequently see things like "ineffective coping r/t personal vulnerability, aeb impaired adaptive behavior." As a psych NP that's virtually useless... is the patient coping through maladaptive mechanisms, or are they not coping and having a melt down? If the former, what are they doing behaviorally that you're interpreting as ineffective coping?

I apologize if any of this is annoying or offensive. It just bugs me when I work with a really good nurse and their note is totally useless to me, especially when so many of them can say what's going on when they talk to me.