1st person care plans

Destinystar · Jun 9, 2004

before i can answer that question i need an example of one of those care plans. care plans should be individualized that is written for that specific resident and meet the standard of care guidelines, the nursing practice act, and the state and federal regulations. everyone interprets those in a unique way and its reflected in the different styles they use when they write a care plan. its not how it is written but what is written that counts. anything brief and to the point sounds good to me.:)

kilbylake · Jun 10, 2004

before i can answer that question i need an example of one of those care plans. care plans should be individualized that is written for that specific resident and meet the standard of care guidelines, the nursing practice act, and the state and federal regulations. everyone interprets those in a unique way and its reflected in the different styles they use when they write a care plan. its not how it is written but what is written that counts. anything brief and to the point sounds good to me.:)

an example would be something like this:

my name is jane doe, and i am 85 yrs old. i am diabetic, so please offer me sugar free snacks. my blood sugar tends to drop in the late afternoon, so please check my b.s if i seem shaky or weak. i can be unsteady on my feet and need assistance when walking long distances. sometimes i am incontinent, and need to be checked frequently for wetness. i am at high risk for pressure sores, please remind me to repostion every hour when i am in my wheelchair. etc. etc. etc. etc.

it is very important, i agree, as to what is written. however, if it is in a form that is inviting to read, that is the key. our present care plans are very intimidating, they read and appear like the stiff legal documents that they are. for nurses and cna's who are responsible for 40 residents on their shift, it would be like asking them to open a webster's dictionary and start reading in their spare time. my example is probably pretty lame, as it is late and i'm spent after a long day, but hopefully it will give you an idea of what i'm writing about. thanks for your interest and help!

Destinystar · Jun 10, 2004

according to obra federal guideline f279 "the facility must develop a :uhoh3: comprehensive care plan for each resident that includes measurable objectives & timetables....". federal probe 483.20 (d) (i) "does the care plan reflect standards of curent professional practice?".

in order for you to fully understand this read obra (the federal guidelines), the rn nurse practice act as well as a text book about care plans written by carpentino.

this narrative that you posted does not have goals or measureable objectives. it should state "blood sugar will be 70-100mg/dl" or "residents skin will remain intact with no s/s of redness or open areas

it also lacked a nursing diagnoses that reflected the standards of current profesional practice. it should have stated "at high risk for impaired skin integrity r/t bowel incontinence and immobility"

what it did have were a lot of good interventions. but the care plan is supposed to be interdisciplinary and the health care member responsible for the intervention should be identified i.e.: provide verbal cues for resident to turn and reposition q2h - cna, etc. again that is what the federal guidelines and nursing practice act mandate.

legally you cannot document the word "i" unless you are the author.

you can write a narrative like this somewhere leaving the "i" out but you cannot pass it off as a care plan.

we are responsible for supervising the cna's and making sure that they receive all the information that they need to to take care of the residents. how you go about this is per your facility policy.

if the cna's do not know how to read a care plan or understand its contents then it is the responsibility of the director of staff development to provide inservice education to them about their role. they only need to know what is written in the intervention column that concerns a cna. she can also inservice the licensed nurses to make sure that they write the cna's interventions as simple as possible.

the rest of that info in the narrative is found in the mar & on the face sheet.

:uhoh3:

Rnltc · Jun 12, 2004

I liked the way it read. With a little change you could have measurable goals with in the content. The format you use to put a POC into is up to you. The only thing the Fedral regulattion state is a problem, goal, and interventions and evaluation.

I am not so sure that I agree that you are wrong in using the "I". If the resident or DPOA agrees and signs off there should be no big issue if using "I".

The Fedral Regulations also state the resident must agree with their care and be infomred. The must be part of their own POC.

IT is acceptable to use to POC for a resident. A very short and direct one and then a very detailed one. We call them POC A and POC B. THe POC A is one page and posted with the residents closet and their ADL books. It is a short recap of the Care Plan B.

green_eyed_angel · Dec 6, 2005

Our nurse consultant was in today and thought our first person care plans were too light,even though I've managed to add approaches and goals. It's like I'm sitting down and writing short stories about my residents everyday! Just when I think I'm getting the hang of it..somebody else comes up with something different to put in them. I don't know about you, but there's only so much fluff I can add. I'd rather get down to the meat.