Care Plans in Adult Medical Day Care

[mrsamjones]

I am a DON in an Adult Medical Day Care. I know each state has different regulations for the AMDC. I am driven bonkers by the regulation in the state I am in that requires a care plan for each diagnosis that the patient has, whether it be an active diagnosis or a past history of a disease process such as, breast cancer w/mastectomy. I often have to force the care plans. We are also required to write care plan comments in addition to monthly notes, nursing care note notes, and quarterly assessment notes. The triplicate documentation is crazy!

What does the state require for your AMDC? Also, what do you write in your care plan comments? I usually try to write a small sentence for each care plan addressing if it is continuing, have goals been met, and the need for it to continue forward.

Also, don't you hate that the care plans are now also plans of service aka the services you are providing for the client. When did it move away from nursing care plans?!

[Jedrnurse, BSN, RN]

A care plan for all PMH Dx? That is beyond stupid. They really want you to treat the chart, not the patient...

[Here.I.Stand, BSN, RN]

Care plans are driven by nursing diagnoses, and nursing diagnoses are driven by assessment— not by medical diagnoses.

Your state’s reg is stupid

[OldDude]

Obviously your facility if reimbursed by the state so don't try to apply objectivity or reason to anything.