Paper Charting and Plan of Care

[marooon13]

Does anyone still have paper charting (or partial)? Or remember what it entailed when you did? What did your nursing diagnosis plan of care look like? Risk for unstable blood glucose level r/t ... (Active/Ongoing/Resolved)

Background:

We currently use computer documentation. Our new manager has pointed out that we do not have a proper 'plan of care' section in our charting (which is a hospital requirement). She has put together a group of nurses to create such a document. We met with the computer optimization team and they won't be able to make any changes to our computer documentation until 2017. For the time being we must make a paper version of this.

We are struggling with the format. I have past experience with this in EPIC. Each shift, we would 'review' the care plan and could change status of the issue at any given time. For example, the infant was having feeding intolerance but that is no longer an issue. The nurse would change the status from an 'ongoing' state to 'resolved'. Lets say in a week, the infant revisits his feeding intolerance. We were able to again change this from a 'resolved' state to 'activated' again. There was also a section for comments so you could justify the change in status.

If we were to put this in paper charting, you could erase and change the state of the issue but then there is no paper trail, and really no proof that we have been addressing it every shift.

Thoughts?