Care Plans-Are you doing them?

[Tait, MSN, RN]

I have heard certain rumbles and rambles that due to the high turn over of patients and increasingly short stays JAHCO isn't as ardent about care plans.

I know we are still slapping them together to make our clipboards happy, however has anyone else removed them from the paperwork? Or have any info on this rumor?

[racing-mom4, BSN, RN]

We use computer charting where we can click on a variety of care plans that will pop up when we key in the admiting diagnosis and the working diagnosis..those "plans" stay at the top of the computer chart...we can then click on them and update/completed/modified/discontinued ..so technically yes we are doing them--

[Halinja, BSN, RN]

We don't do them

[VickyRN, MSN, DNP, RN]

In the teaching hospital in which we have our clinicals, they are using careplans. They switched from "carepaths" to careplans last year. Almost all charting in this facility is electronic, so the careplans consist of "preset" nursing diagnoses and goals and qshift evaluation of the progress of the goals.

At my secondary employer (small community hospital), we have a paper chart careplan. This consists of nursing diagnoses which are "checked" upon admission and then evaluated with every nursing narrative note (through a number key system). New nursing diagnoses can also be activated PRN.

Not sure why the teaching facility switched from carepaths to careplans. I remember hearing it had something to do with JCAHO, but not certain. I'll have to ask next time I'm there.

[emnicams]

We still do care plans (Excelcare) but have removed them from the paper charts.

[nrsang97, BSN, RN]

We still do care plans (Excelcare) but have removed them from the paper charts.

We use the same thing. I think it is almost pointless since no one reads them anyway.

[stpchc]

I work in a MN hospital and Joint Commission was just here..............and yes they still want care plans. The focus was on how we individualized care plans along with risk assessments on falls, skin, pain were included when risk was assessed. We are doing everything electronically for nursing documentation using Cerner. Our care plans electronically are still being tweaked to become an active part of our care that we are doing. Some of our documentation automatically updates pieces of the careplan but other parts still needs to be done separately. Many of our nurses are not always doing that part...................I think in part because of all the EMR changes over the past 2 years and the care plans continually being changed/updated to a better way of doing them. So keep doing those care plans!!

[Virgo_RN, BSN, RN]

We assign nursing diagnoses to individual patient problems, then select the appropriate care plan. This is all done in the computer, mainly for JC compliance. In actual practice, we do what makes sense to do for that patient.

[Tait, MSN, RN]

I will be so happy later this year when we get our computerized charting up and running. Thanks for the responses!!