Care plans...what is and isn't necessary

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Specializes in Gerontology, Med surg, Home Health.

I had a discussion with one of my friends who works in a different facility. She says her boss tells her that she has to care plan EVERYTHING...every med, every treatment, even if it's not a problem, because they are POTENTIAL problems. At my facility, we don't care plan every med...crikees, some people take 27 meds not including OTC's. I think I'm right and she doesn't know. Can anyone shed some light on this?

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I care plan psychotropics, antidepressants, pain meds, coumadin (and the like) and use a temp care plan for antibiotics. This isn't one care plan for each - I usually put the pain in with the ADL, psycho and antidepressants in with mood/behavior - like that. So for this has passed state inspection for me.

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Specializes in MDS coordinator, hospice, ortho/ neuro.

I care plan meds like this: (esp. the catergories of drugs with side effects that lead to falls, dehydration, mental status changes)

Diuretics as ordered. Montior for sx dehydration / electrolyte imbalances. Obtain labs as ordered.

For treatments I mention the site, and type of wound but put tx as ordered.

The care plan is not a substitute for the MAR / TAR. If you put specific drugs /tx then you have to update everytime the dose is changed.

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Specializes in LTC, Hospice, Case Management.

Oh please. If you care planned every "potential" you'd never have any time to give care. The potential for exposure to every illness all the other residents have, the potential for the roof to collapse on them, the potential to stub their toe, etc, etc... it would never end. Complete insanity. I agree with what one of the others states - i careplan coumadin (Lovenox and heparin), insulins, all psychotropics/hypnotics, diuretics - only if I feel there is a real chance of altered fluid balance related to severe CHF w/ fluid restrictions and the like (as opposed to someone on same dose for years and stable), pain medications/with the care plan for pain, and antibiotics. I have NEVER heard of anyone care planning every single med and have never seen a requirement in federal regulations to do so. Maybe you could ask her to back this up with a reg. requirement that she is aware of. Good luck

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I agree with the previous posts. I make sure all my Raps are covered, and even then I combine problems as much as I can. I also care plan anticoagulants, dig, etc.

OMG, the care plans would be 500 pages long if you careplanned every med & dx!

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I have to care plan everything!

Sucks and I never go home in time with all the daily incident reports I have to do.

Thank god I'm only an LVN part time and I get to sit on my can once in a while as a teletech (with practically the same pay!)

VARIETY! that's my word.

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I agree with the previous posts. I make sure all my Raps are covered, and even then I combine problems as much as I can. I also care plan anticoagulants, dig, etc.

OMG, the care plans would be 500 pages long if you careplanned every med & dx!

Sucks care planning Coumadin.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Your friend's boss is saying this because each care plan has to reflect the doctor's orders and all the other services that are being provided for the patient. This all ties in with the required MDS reporting to the Center for Medicare Services. A lot of LTC facilities have a specific nurse who supervises and maintains the care plans because they have to be very detailed and specific. That is what this person's boss is on about. Yes, there are such things as potential problems on care plans. Potential problems are how the care plan justifies things like fall precautions. When the state comes in to survey a facility they will scrutinize the care plans for their completeness and detail. It sounds like your friend's boss might have had some personal experience with the surveyors about the quality of the care plans in her facility.

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Your friend's boss is saying this because each care plan has to reflect the doctor's orders and all the other services that are being provided for the patient. This all ties in with the required MDS reporting to the Center for Medicare Services. A lot of LTC facilities have a specific nurse who supervises and maintains the care plans because they have to be very detailed and specific. That is what this person's boss is on about. Yes, there are such things as potential problems on care plans. Potential problems are how the care plan justifies things like fall precautions. When the state comes in to survey a facility they will scrutinize the care plans for their completeness and detail. It sounds like your friend's boss might have had some personal experience with the surveyors about the quality of the care plans in her facility.

We care plan everything too. It's only about 3 or 4 pages long since it's on puter. But our orders rarely change so its the same month to month basically.

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We have a care plan nurse. She does all the care plans but it bothers us that she doesn't discuss the needs of the patients with us. We deal with them day to day and she assesses them weekly or monthly. It is also impossible to find where she hides them. :behindpc: :sofahider::chair: :rotfl:

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Does anyone actually read them? They get ridiculous after a while, esp. if you're using NANDA.

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Specializes in Gerontology, Med surg, Home Health.

I care plan what I have to but not much else. I go by the JCAHO regs....specific measureable goals...blah blah blah. We have a really hard time getting the nurses to properly update the care plans. They change the goal date and think that's updating it!! We've had patients admitted to the subacute floor who then become long term. Makes me chuckle to see the care plan I wrote for them on admission still there 5 years later when it has nothing to do with their care today....if I didn't laugh, I'd cry.

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