What’s Wrong with Care Plans—and How to Get it Right
Holly F. Sox, RN, BSN, RAC-CT - Clinical Editor, Careplans.com
Long-term care professionals across the country write or participate in writing care plans for thousands of nursing home and rehab residents each day. The care plans must be thorough, yet brief enough to be useful. They must be comprehensive and individualized. They must be up-to-date and comply with current standards of practice, state and federal regulations. It’s no wonder that the care planning process is often frustrating and time consuming.
Experts and consultants give conflicting information at times, and trying to predict what a surveyor will like or dislike feels like a guessing game. Should we use “I” (first-person) care plans? Should we use columns or write a narrative? Should anyone ever use “canned” care plans? What’s the best reference book for writing care plans?
What is a Careplan
Holly F. Sox, RN, BSN, RAC-CT -Clinical Editor, Careplans.com
Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Without a specific document delineating the plan of care, important issues are likely to be neglected. Care planning provides a "road map" of sorts, to guide all who are involved with a patient/resident's care. The care plan has long been associated with nursing, and many people believe (inaccurately, in my opinion) that is the sole domain of nurses. This view is damaging to all members of the interdisciplinary team, as it shortchanges the non-nursing contributors while overloading the nursing staff. To be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of this patient/resident.
The first step in care planning is accurate and comprehensive assessment. In the acute care setting, a thorough admission nursing assessment should be followed by regular reassessments as often as the patient's status demands. In the long- term care setting, the MDS (Minimum Data Set) is the starting point for assessment. Home health utilizes the OASIS assessment. Other settings will have established protocols for initial assessments and ongoing reevaluation.