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

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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?

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

We never "care planned" meds. We had to write up "drug cards" for each one.

I hated that exercise, but it makes more sense than "care planning meds" to me.

We never "care planned" meds. We had to write up "drug cards" for each one.

I hated that exercise, but it makes more sense than "care planning meds" to me.

Was this for LTC? For school we had to do the drug cards, but I think this is dealing more with the LTC pts.

Try checking the AANAC site or Careplans.com. They are excellent.

When I do my care plans I have basic problems that all new admissions have. Skin, Mobility, Pain, Constipation if they have pain and take meds, Bedrails, ADL's, Fall and then the rest I care plan is depending on their admitting dx's. CHF, COPD, FX's, etc. Any psychotropic meds, coumadins and diuretics. I always care plan tx as ordered. Never put the exact tx down on your care plan. If your facility is like mine, that could change daily and you will get screwed if nobody changes that care plan. Social services careplans their own issues, behavior, mood, anxiety. Recreation and dietary do their own too. I guess I'm lucky, just have to worry about nursing issues. But that too can be tiring. Some people are so complex. I always feel that I will leave one thing out. When I was orientated at my facility, I was taught that you should be able to white out a resident's name on a careplan and show it to staff, and they should be able to ID who that careplan is about with no name on it. That could be pretty specific and I think it sets you up for failure if you try to be that specific.

I do all the careplanning on my 40 bed unit. I've made a template on the computer loosely based on the GOLD book (Careplans That Work with MDS?).

Over the years, we've changed our language to get the surveyors off our backs. Instead of goals like "Will not fall this quarter (which is easily NOT met)," our goal is now "Risk for falls will be reduced." Pretty much the same interventions.

I've also pulled out all the basic careplan 'guts' that goes into every single careplan in the universe. We have a Standard of Care Comprehensive Careplan separate from the individualized one. Things like, "Will be approached in a calm and respectful manner," and "mouth care will be provided," are in there.

Now when I start an individual careplan, the first intervention on each RAP based page is "See Standard of Care Comprehensive Careplan." No more weeding through all the common stuff to get to the real essence of this individual's care.

As far as meds go, by giving me a license, the state of NY has deemed me competent to recognize adverse effects of medications. My careplans are not designed to be a pharmacology education course. I enter, "Administer antihypertensives/diuretics/cardiac meds per doctor's order and evaluate effectiveness, report to adverse effects to RN/MD."

I find our careplans are now more meaningful and easy to read than when I was just writing to, what felt like, entertain and amuse the surveyors. And I actually have time to see my residents instead of typing at a computer all day.

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