Care Plan on the job

[sillymu, BSN, RN]

I'm currently in the 2nd semester of the first year of my ADN program and I am wondering how many nurses are using care plans in practice. The two hospitals we where we do clinical (we live in a very rural area in central New York) don't use this as a practice on their floors. We've been writing care plans every 2 to 3 weeks. I do not mind doing them as I am learning a lot about treating disease processes, but I just want to know if it is something that nurses outside of our area are doing on the job.

I plan on moving to California or the south after graduation, but I am curious to hear from people everywhere. Have you used a care plan or written one since graduation while on the job?

[Eris Discordia BSN, RN]

The position that I am in now is the first position where I have to actually WRITE a care plan for every admission...

Now, we have had actual care plans for every patient in every other job I've been in, created on admission, but creating one was a matter of just clicking on pre-made care plan components that had already been written out. Click on "impaired skin integrity", boom, giant pre-made care plan pops up! Or click on a certain pathway and a completed care plan files in the chart automatically.

With this job, I actually have to go thru the tedium of writing one out in the EMAR, nursing diagnosis, rationale, personalised "as evidenced by" and all. I have to come up with the interventions and evaluations list like I did back in nursing school. It's a time suck and I know the prewritten ones are more comprehensive and better than the one I'm writing at hour 15 of my shift when my brains cells are jumping ship.

I don't know if the facility got dinged for not having a super personalized care plan for each individual...and that is maybe why they do it this way? I will never know why we do it this way.

But it's a licensing requirement for every patient to have a care plan on file somewhere...just because you don't see the nurses writing one, doesn't mean that they don't exist. Even federal reimbursement thru Medicaid/Medicare is contingent on patients following national "care paths" for specific diseases such as pneumonia, MI, and stroke.

So, every patient definitely has one, even if you don't see nurses writing one. They may just have to click a couple buttons on admission for one to auto populate and you wouldn't know what they were doing unless you were carefully watching an admission or digging thru the chart to find one. And they aren't always labeled "care plans". My facility calls them "recovery plans". Some places I've been, night shift is the one that writes the care plans. It widely varies.

That being said, no, not a lot of nurses are out there writing an old fashioned care plan. But in school, the process of writing the care plan is the educational part. It's the information you learn and the critical thinking you gain putting one together, learning how to decide on interventions for a specific process and how you could critically analyze if those interventions worked. That critical thinking, that deciding what to do for what, and then informally analyzing whether or not what you did worked...that is massively valuable and the real reason behind why you spend so much time on it.

Yes, you.may end up writing a classic school style care plan in the real world. You also may just have to initiate a pathway on admission. But all patients have a care plan of some sort or another tucked away somewhere.