Do Registered nurses really make a Nursing Care plan for their patients?

burn out · Feb 28, 2007

Yes Virginia, Santa Claus and careplans do exist just as sure as there is a JCACHO. If you don't believe me just look how quickly careplans appear when it is survey time.

fultzymom · Feb 28, 2007

i am just wondering if the registered nurses really make a nursing care plan (ncp), because in our hospital, they don't really make ncps, but as a student, our professors always instructed us to to make ncps. i know its a part of the lesson but im just wondering why in some hospital, they dont do ncps... pls reply if you already read this post. thanks.:nuke:

i work in ltc et when the patient comes in there are "standard" care plans in place. then as the mds nurse (me) reviews the chart et does the medicare assessments, we update the care plans et put in specific care plans for that persons diagnosis, needs, ect. the only thing the floor nurse has to do is initiate the "standard" care plans when the patient is admitted.

jojotoo, RN · Feb 28, 2007

We don't have NCP in my ER, but we do have an assortment of nursing diagnosis that are addressed in our notes. 99.999% of my patients get Knowledge Deficit because I can teach EVERYONE something (unless you are DOA and arrive without any family or friends).

Then about 95% get Pain R/T whatever the complaint is.

And there is always an assortment of Alteration in Body Temperature, Impaired Skin Integrity, Impaired Mobility, etc. Nothing too fancy.

pagandeva2000, LPN · Feb 28, 2007

I'm an LPN that does not have to do careplans, but, I have seen that my hospital has pre-printed care plans that the RNs use depending on the diagnosis, with basic interventions, with space to add as needed to make it individualized.

Agnus · Mar 4, 2007

Sometimes a nurse will not recognize that she does indeed do care plans. That is because they take a very different form from what she learned in school and are often pre printed pre formatted, and may go under a variety of names other than "care plan".

For example in one facility I worked they were called a "Map" and it was preprinted and all the nurse had to do was to check boxes as the pt met each expectation. Were I work now they refered to as Standard of Care. It is computerized and spits out a "work list." It however is verymuch the plan of care for that patient.

The detailed hand written care plans you do in school are a very important learning tool. They never werer meant to be done in anything but an acediemic setting for purposes other than teaching students.

Bluehair · Mar 4, 2007

Our care plans are also generated by computer at the time of admission based on the patient's diagnosis. You can have more than one diagnosis which will add more things to the care plan. We are expected to update the care plan every shift as well, adding new items or removing those that are no longer applicable.

Tweety, BSN, RN · Mar 4, 2007

I thought care planning was a JACHO requirement. We use them, but they are pre-filled out and we just check which one's apply to our patient.

RNHawaii34 · Mar 4, 2007

yes. We do it, and even read it even if you didn't do it yourself...it's required....

Daytonite, BSN, RN · Mar 5, 2007

josepito3. . .here in the United States a nursing care plan written by an RN is required to be in the charts of all patients who's hospitalization is being paid for in part by Medicare (our federal government). That is pretty much most of the people over the age of 65. In addition to that, any hospital who accepts Medicare payments for Medicare patients MUST abide by the Medicare rules for all their patients, and that includes having a written care plan on every patient even if they are not being paid for by Medicare insurance. So, for most acute hospital patients, a written care plan by an RN is required. Now, many facilities have gone to different lengths to make this as painless for their RNs as possible. But, the law is still in place here in the U.S.

caroladybelle, BSN, RN · Mar 5, 2007

i am just wondering if the registered nurses really make a nursing care plan (ncp), because in our hospital, they don't really make ncps, but as a student, our professors always instructed us to to make ncps. i know its a part of the lesson but im just wondering why in some hospital, they dont do ncps... pls reply if you already read this post. thanks.:nuke:

to my knowledge, ncps are required by jcaho in all approved hospitals, on inpts.

as to what form that they take, that differs.

most places have a preprinted general form, where you place check marks, or utilize a form of charting that incorporates it. soap and dar charting often utilize basics that are a form of ncp.

computer charting usually has a "problem list" that is ncp based.

even outpatient surgery has forms, that one checks off for teaching and outcomes.

they are not called "care plans" always but encompasses it in form.

er, i don't know about.

Cattitude · Mar 5, 2007

to my knowledge, ncps are required by jcaho in all approved hospitals, on inpts.
as to what form that they take, that differs.
most places have a preprinted general form, where you place check marks, or utilize a form of charting that incorporates it. soap and dar charting often utilize basics that are a form of ncp.
computer charting usually has a "problem list" that is ncp based.
even outpatient surgery has forms, that one checks off for teaching and outcomes.
they are not called "care plans" always but encompasses it in form.
er, i don't know about.

i'm going to admit i felt like a complete fool reading this entire thread thinking i never saw cp's at my jobs.

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[color=#483d8b]until i read your post. thank you! i now realize that sure i saw them, just disguised very, very well in my pre-printed nurse's note/charting. now in home health it appears they are incorporated in our computer charting. i'm not a big fool after all:imbar . maybe just a little one:specs: .

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