Careplna... Question from a current Student

[FocusRN]

Okay everyone always makes such a big deal about care plans, and rightfully so as they are very important. But my issue is the deal students make about writing them on this forum and others, including myself. In school writing one on the spur of the moment can be a terrifying experience if not prepared (really prepared). What I really want to know is, as an RN, whatever your educational level, how do you write you care plans? For example truely from scratchs, or from your facilities preset form (eletronic or paper), or some other resource?

[GingerSue]

when in the home, would write the careplan in the home notes

based on my assessment (that must be from scratch)

[VRN-RN]

My school uses PACPD tool online. its a guide. but we still use our mind to write one out. its challenging at times but you get through as long as you prioritize. It really isnt a big deal. My school makes a big deal out of them. you get used to it after 3rd one.

Okay everyone always makes such a big deal about care plans, and rightfully so as they are very important. But my issue is the deal students make about writing them on this forum and others, including myself. In school writing one on the spur of the moment can be a terrifying experience if not prepared (real prepared). What I really want to know is, as an RN, whatever your educational level, how do you write you care plans? For example truely from scratchs, or from your facilities preset form (eletronic or paper), or some other resource?

[HisHands, ASN, RN]

Our facility has complete careplans, all alphabetized by dx. All we have to do is date and sign them.

Blessings,

Crystal

[crissrn27, RN]

We have a computer program also, with pre-selected dx, orders, goal........from a former careplan nurse (now in newborn nursery), it really ticks me off that we can't alter them to make them pt specific. I am sure I am the only one who has this complaint, lol.

[Imafloat, BSN, RN]

We have a list of priorities of care. They are prioritized and we select a few and write them on our daily trifold. The careplan writing in school is to teach you to think like a nurse. I hated careplans and didn't understand their purpose while in school. Now I see how much the process of creating them taught me.

[meandragonbrett]

Ours are point and click, click print, and slap it on the chart.

[bdeherr]

We have pre-written careplans, but also have the opportunity, and are encouraged to, individualize them for our patients. As you are going through your admission process, jot down those areas that will be a particular concern for your patient. Care plans really are valuable!

[Daytonite, BSN, RN]

you must understand that there is a difference between care plans that are done as school assignments and care plans that are done as a requirement of a job. there are some similarities, but also some differences.

first of all, school is school. in school you are working for a diploma or degree from an institution of learning. a care plan done for school is pretty much a creative endeavor that can be comparable to a term paper. yes, you have to know the nursing process and utilize nursing fundamentals and knowledge. but, many schools also want to see a demonstration of a command of the english language and that the student has followed the directions given for the assignment. that is something that is academic and has to do with fulfilling the learning institutions goals for all it's students.

second, a written care plan is mandatory to be included as part of the permanent medical record of any facility that provides services to medicare patients. this mandatory requirement is in title 42 of the federal law for the medicare conditions of participation. the written plan of care can pretty much be in any kind of format, but it must be done by a registered nurse. for this reason, nursing schools have a duty to teach every rn student how to write a care plan since it is a job requirement unless you find yourself employed in a doctor's office where care plans aren't required or done. but, in today's world it is likely that you will be giving care to patients, part of whose bills are being paid by medicare and medicaid. the law is very clear about a care plan being present in the medical record of all the patients who go to facilities that provide care whether each patient receives medicare/medicaid or not. as long as the facility accepts medicare/medicaid funds from the federal government, they must comply with the laws of title 42.

third, writing a care plan is a nursing skill. unlike the more physical skills that students are used to having to learn, this care plan business is more of a mental and thinking skill that involves using critical thinking. most students come to nursing schools pretty short on this critical thinking skill. it's something that you learn over many years and cogitating on the things you have done and why they did or didn't work out. it takes time to master skills. writing a couple of care plans in nursing schools doesn't make you a master at them. while there may only be two or three different brands of a foley catheter for you to use and become familiar with, there are 188 nursing diagnoses, many of which you may never use at all over the course of your career. depending on the area of nursing in which you work, there will be some medical conditions you will never see in your clinical work so you will not be very masterful in treating one of those patients if they do happen to show up where you work. there will be a certain number of nursing diagnoses that you will use again and again and you will become very familiar with them; there will be some nursing diagnoses you will never use and if you find that have to, you'll be hitting a reference book (taking up time) to figure out just what that diagnosis is about.

i've written care plans in all the places i've worked over the years. in many places we hand wrote the care plan from scratch. in the more recent past, the hospitals have had the "canned" forms. i was on the committee at one hospital that created and periodically reviewed those skeletal forms that the staff used. i have also seen the newer commercially produced mix and match care plan software programs. what is going on is that facilities are trying to comply with that title 42 medicare requirement of having a care plan in every medical record as well as trying to free up their rn staff from doing this task so they can focus on direct patient care. at some point, someone realized that there was repetition and redundancy in doing these care plans. however, the human eye and brain of an rn still needs to review and evaluate the plans that these computers spit out to make sure they make sense and follow nursing process and critical thinking.

[fultzymom]

We have six basic plans that eveyone gets when they come in. Then when we do the MDS assessment, we initiate care plans based on their specific diagnosis. Ours are on the computer et we can make any changes that need to be made on the computer them print them out.

[mamason]

My facility uses a computerized system charting. At the end of the admission assessment, the care plans that match this particular patient, will appear on the computer screen. Then, you choose which ones fit best fot that patient. It's easy. I remember writing them in school. Time consuming, but, a good learning tool.