Nursing Diagnosis are used extensively in home care to focus on and document what you are doing in the home. Our nursing note (2 pages) has diagnosis codes at the top of page 2--we document teaching done based on diagnosis underneath: checkmark format with areas for individualization. They are a big help in going into a home cold as a relief nurse.
We also use several standardized care plans
along with visit flow sheets for our specific programs: CHF, COPD, Diabetes, Gestational diabetes, Post partum so that we are all teaching the same things on visit # 1, 2, 3, 4 etc and helps prevent redundence + missing teaching something in the days of managed care. Some patients will have only 1 or 2 nurses see them....others wind up with 6 - 8 different RN's if needs extensive, long term wound care, difficult mgmt, needing weekend visits, vacation coverage etc.
So if i am seeing a COPD patient on visit #3, I know that I am to focus on CP assessment, review of correct inhaler/nebulizer use and teach pursed lip and diaphramatic breathing, teach medications 5+ 6 on med list (if more than 4 meds listed) and evaluate prednisone taper and side effects( if pt using med). Explanation of diagnosis and meds 1, 2, 3, 4, already taught----that way 3 nurses aren't all teaching Prednisone use and theodur but forgetting teach difference between albuteral and steroid inhalers with their potential for oral thrush.