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?

We have a single plan of care packet that we chart on throughout the infants hospitalization- We sign off on it when certain tasks are completed (ie IVF started at 80ml/kg/day, temperature stabilization, feedings tolerated, teaching parents, etc). There are about 10 different categories you can chart on (Assessment, Nutrition, Teaching, Immunizations, Medications, etc). In my old NICU, we had our POC integrated into our computer charting. It is to be addressed every shift, so if we increased feedings I would choose to chart on the nutrition section and free text "infant tolerating increase in feedings." At the NICU I am at now, they were unable to get a proper POC with our computer system so we still have it on paper, which does not give us the option to free text. It is basically, like I mentioned, a list of check offs throughout their stay. However, it cannot be individualized to the patient like computer charting can be. There are many tasks that only apply to half of our population, so a group of us were asked to revisit this. I am just curious if other people have this in paper form and what theirs looks like. We would love to just do away with it but it is a JCAHO requirement to have a POC.

JCAHO is the Joint Commission on Accreditation of Healthcare.

Hi All! Our NICU is about to begin the process of creating a new Neonatal Pathway/ Plan of Care. According to JCAHO, a plan of care is required but it does not list specifications. I have worked for two NICU's and ours were completely different so I am reaching out to see what everyone else does for theirs. If you could help us out it would be greatly appreciated!!! The one we are currently using is on paper (and will stay this way) and is about 7 pages long. We are attempting to shorten/condense it. Does anyone have a shorter POC they would be willing to share details about? Thank you so much in advance :)