sheebs_

We actually use PCC and I find the templates are very basic. In fact, in our other facility (under the same corporation) said their state surveyor mentioned PCC's care plans not being adequate enough. I prefer to use the "potential for inadequate cardiac output r/t HTN" as well but the PCC template just states "the resident has HTN" and then some wonky goals. The interventions aren't bad...I'm just having issues with their problem templates.

I'm new to the LTC setting and was just recently promoted to director of nursing. I'm in charge of initiating care plans for all the residents in my facility. I've been told that if a resident is admitted to us with a medical diagnosis of "hypertension", then we can write our problem in the care plan as "the resident has hypertension". To me that doesn't seem right. I was just wondering if anyone could help me transition into this new position more easily. I feel like I'm not getting very direct answers and being that I'm kind of a perfectionist, I want these care plans to be done completely right. I always thought we could only write a nursing diagnosis in a care plan problem so any help or direction would be greatly appreciated! Thanks!