Care Plans, Care Plans, Care Plans...

[A Kitty RN]

I just recently started an asst. manager position on a Telemetry floor. We have also recently had a visit from State. Seems our Care Plans are not individualized enough. Right now we use hospital made care plans for various illnesses/situations, (e.g. MI or Cardiac Catheterization).

In order to keep our hospital functioning we must change our care plans ASAP. We are trying hard and fast to find new ways to make sure New care plans will be easy to individualize and include all of the patients current and significant problems (Y'know, pt. has MI but is also diabetic and has old CVA).

PLEASE!!!!!! If anyone has any advice it sure is welcome!

By the way, we are a wonderful hospital that puts patient care above everything

I suppose it is our documentation we need to improve on.

FYI- we use charting by exception

[Janis Noone]

I know this will not be the answer you would like to hear but in order to meet state/CMS regs you do have to have a current and updated plan of care. If what you have at least gets a plan started then all you need to get staff to do is to update with the most critical info each day. I know they will think you are asking for them to write care plans like you saw in school. This is not what they want to see. They want to see the most important info communicated on paper on the plan. Don't forget all restraint patients must have a plan for restraints on the plan too. If you look at the regs for patient rights there is a section that speaks to what they want to see. I know this is tough work to make happen. Consider looking at alternate formats that assist staff and make it as easyand intuitive as possible.

Jan

[BadBird, BSN, RN]

Why not start a care plan committee, assign each nurse that volunteers one care plan of their choice such as MI, OD, CHF, you can also look online for careplans and alter then to fit your needs.

[A Kitty RN]

Thank you for your advice. We did start a committee!