too specific or not specific enough?

All of the care plans that I have seen have been in school. All of the plans of care i've seen in the hospital were very general guidelines that were selected from a list off of the computer. The computer based the list off of selected problems entered into the computer from the admission assessment. No new problems were planned for unless entered by the RN. It seems to me that if you have time to be typing up care plans, you could actually be providing care to the patient.

I agree with your new place, I write "adm Psych meds as per MD order" and havent had much of a problem with it, if you are too specific you really have to have someone update the care plan with every new MD order or change in PT therapy etc,

It all depends on your staffing,

We dont have enuf staffing to update the careplan every day...

I care plan wound treatments and just as a side note we just had an inspection. The wound nurse did not do a wound sheet or tx order. I was not aware of the wound and got a ding from the state for not having a care plan. Good luck.

hi.

you did not "get a ding"--somehow your facility and many many others confuse day-to-day assessment, documentation, and notification responsibilities with "program" responsibilities.

why is the wound nurse responsible to start a skin record and obtain a treatment order? where is it written that the mds coordinator (or any one person) is responsible for maintaining the interdisciplinary plan of care?

a professional nurse working for the facility must:

1. assess any new problem (skin, behavior, temperature, etc.) when found.
   
2. document his/her assessment.
   
3. report this new problem (and associated findings) to the physician for treatment and/or follow-up.
   
4. report this new problem to the resident and/or his/her family.
   
5. document (and report to other professionals) the problem, new orders, and any other actions taken.
   

therefore, the unit nurse/staff--or facility--is responsible.

although surveyors (and your staff) may want/need to see a specific care plan for this problem, the facility cannot be cited for deficient care practices if the nurse's actions meet professional standards of care. the documentation is a care plan.

why do we continue the mantra--

and we disregard the "basics"--

adding to, correcting, or communicating the plan of care is the responsibility of facility clinicians.

hopefully, your facility's poc (and future actions) will show interdisciplinary responsibility for planning care and monitoring care outcomes.

good luck! :innerconf

I would definately just put the classification of the med-not the specific name. And as far as other nurses transcribing orders and tx's on careplans-where I work at the MDS/Careplan Coordinator is the only person that does anything to the careplan. It works out well that way. But I have worked in facilities where the nurses that get the orders are responsible for transcribing them on the careplan, and it worked fine to.

i DO CP FOR PSYCHOTROPIC MEDS BUT I INDIVIDUALIZE THEM BY PUTTING WHAT CURRENT MED THEY ARE ON. IN OUR SMALL FACILITY I CAN USUALLY REVISE BECAUSE THE MEDS DONT SEEM TO CHANGE THAT OFTEN. WOUNDS- WE USUALLY PUT IN THE CP THAT IF THE CURRENT TX NOT WORKING TO LET MD KNOW IN 2 WEEKS THAT THE CURRENT TX NOT WORKING.