Careplans in your head?

[Troischats]

Hello all,

First off, I'm in nursing school, so not officially an RN, but if you'll allow me to stick around for just a sec to ask a question... I'm very curious as to how you go about care planning once an RN. When we first started school, and care planning, I thought if nurses are soooo busy how on earth do they have time to sit down and do all this? That's when an instructor said, you don't, you do it in your head, multiple times each day. I guess I'm wondering if there is documentation you have to do as well in regards to care planning? What's the procedure? I simply don't know!

Best wishes and thanks much for your time!

[jill48, ASN, RN]

I agree that after doing it so long, most of the care planning is in your head. Everywhere that I have worked, the careplans are already in forms and divided up by diagnoses. So if I had a patient come in to get a colostomy, I would look that up and find multiple forms, such as the altered body image one (it's been awhile, sorry I don't remember the exact name). But it is always good to try to refresh yourself on these, dividing the plans up by diagnoses is not an exact science, you never know when you can use another one from a different diagnosis. I actually enjoyed writing up the careplans when I was in school. Am I a weirdo or what?