Care plans, why am I still doing them?

[MEDICJOHN]

I get that care plans in school are meant to teach the process of nursing. Now that I am a working nurse, why am I still doing them? Who do they benefit? I don't need to check boxes to know how to care for a patient. I don't need to chart out how I will assess for pain, resp status, bleeding, infection, etc etc, I already know how to do those things. And certainly the patient does not care about a 6 page fold out of checked boxes, they just wanna get better or feel better.

So who are these time consuming chores benefiting? I compare it to a state of the union address. When the president gives his speech, no one stops him and asks "how do you spell military." A. Its assumed he knows how to spell military. B. Its assumed the press already knows how to spell military. C, It doesn't matter how its spelled, it matters whats in the content of his speech.

So, all you educators and/or managers, what are your thoughts? Why do I still do care plans?

[Tait, MSN, RN]

Check these threads, huge discussions already in progress.

https://allnurses.com/general-nursing-discussion/comparative-relevancy-nursing-584997.html

https://allnurses.com/general-nursing-discussion/nursing-diagnosis-sacred-576921.html

[klone, MSN, RN]

JCAHO

[BonewaxRN]

You've learned how to take care of patients. What the care plans you are doing now are intended to do is to document in an objective way what it is that you do to accomplish that. "Taking care of the patient" is what we do, but the care plans show clear goals, what we intend to do to reach those goals, and how we intend to assess the progress in reaching them.

It might not make sense to you to show this step by step, but remember that "nursing care" is not a defined process. We have to spell it out so that it shows what all is a part of that care. Otherwise, we're just part of the room rent and all of your carefully considered interventions may as well be considered random actions with no defined results. It's more than just checking boxes, it's a road map and it's documentation.

[Kyrshamarks, BSN, RN]

Nursing is a non billable service. We are just part if the room rent

[Whispera, MSN, RN]

While nursing is non-billable, a facility must have a plan of care that has goals and documentation of interventions as well as evaluation of achievement of the goals. Insurance companies check for these things. They want this in writing, to prove that the 24-hour caregivers did something. I've worked places where a non-documented time of care led to non payment of the bill.

[wooh, BSN, RN]

They want this in writing, to prove that the 24-hour caregivers did something.

I was going to do something, but I was too busy putting check marks on the care plan.

[RNperdiem, RN]

Political reasons.

Patients somehow survived just fine before the paperwork inflation.

I have a vintage nursing book that showed a picture of nurses writing in patient charts. The whole chart was nothing more than a clipboard.

[MunoRN, RN]

We re-did our care planning process a couple years ago and got rid of the check box style careplan that existed isolated from the rest of the system, it can be found in the assessments, teaching, rounds, etc that we already do. ie, If you do a braden assessment that shows risk for pressure ulcers, the system automatically applies the standard of care for pressure ulcer prevention, you don't have to chart to the individual standards of care although you can individualize it to that patient. Sort of hard to explain so here is a link that desribes a similar process:

http://www.rwjf.org/qualityequality/product.jsp?id=30392

[MEDICJOHN]

lol!!!!! good one!!!

[MEDICJOHN]

If its a billing thing, I'll buy that. But one response I got was "documentation"....still...documentation for who? Its like being in kindergarden.