faq

Frequently Asked Questions

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Are the care plans on this website evidence-based?

Absolutely. CarePlans.com focuses on providing care plans that are informed by current best practices, evidence-based guidelines, and standards of care. Where applicable, sources and references are provided.

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Can I customize care plans from this site?

Yes! Careplans from the libary can be downloaded into Excel or Word, then modifiled. Careplans built in the client module can also be modified. Be sure to adapt outcomes and actions to align with your client’s individual situation.

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Can I print the care plans?

Yes, all care plans are formatted for easy printing. Click on the “Print” button available on each care plan page.

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Can I suggest a video for the Video Vault?

Yes! We’re always looking for useful resources. If you know a helpful YouTube or Rumble video, send us the link through the “Contact Us” page.

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Can I use care plans from this site in my clinical practice?

Yes, but they should be adapted to meet the specific needs of your client and comply with your institution’s policies and guidelines.

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Can I use standardized care plans, or should each plan be individualized?

Standardized care plans provide a great foundation, but they should always be individualized to the client’s specific needs. Tailoring care plans improves their effectiveness and ensures they are client-centered.

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Can more than 1 user access my client records?

Absolutely yes!

Imagine a shared family office where multiple family members work together to manage information about certain projects. Here’s how it works:

  • The "Account" is like the office itself. It’s a central hub where all the work is organized.
  • "Members" are the family members (e.g., Mom, Dad, or a sibling) who have access to the office. Each member can walk into the office and work on the projects.
  • "Clients" are the projects (e.g., a grocery list, vacation plans, or bills) that the family members are managing together.

How They Connect

The relationships work like this:

  • Multiple family members (Members) can use the same office (Account) to access the same projects (Clients). For example, both Mom and Dad can access the grocery list or vacation plans in the office.
  • The office (Account) connects everyone, so all authorized family members can see and work on the same set of projects without needing separate offices.

This setup allows multiple people (Members) to share access to the same information (Clients) through one central system (Account), making collaboration easy and organized.

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Do the care plans include rationales?

Yes! The vast majority of careplans include rationales for outcomes as well as actions.

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Does this site include NANDA-I Nursing Diagnoses?

No, this site does not include NANDA-I Nursing Diagnoses. While we previously licensed the NANDA-I library, we discontinued this for two main reasons:

  1. The majority of our members did not utilize the NANDA-I content.
  2. The NANDA-I library was available for free at https://nandadiagnoses.com.

Given this accessibility, we determined that maintaining a recurring license fee for data readily available online was not a sustainable choice for our platform.

Update 3/23/25: The above URL was taken down and now redirects to the NANDA-I website.

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How do care plans fit into interdisciplinary teamwork?

Care plans serve as a communication tool among the interdisciplinary team, ensuring all healthcare professionals (nurses, physicians, therapists, social workers) are aligned in the client’s care.

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How do electronic health records (EHRs) affect care planning?

EHRs have streamlined care planning by providing templates, real-time updates, and easy access to client data. However, nurses must ensure that care plans remain individualized rather than relying solely on pre-built templates.

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How do I cancel my membership.

Log-in and go to your "My Account" page located in the menu bar. On the "My Account Information" page, select "Member Information.

The Member Information page has three tabs: "General", "Membership Options", and "Payment History". Select the "Membership Options" tab, then click the button labeled "Cancel My Membership".

Fill out the optional fields, then click the button labeled "Yes, Cancel My Account"

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How do I develop a care plan?

Care plans typically follow this structure:
- Assessment: Gather client data (history, physical exam, lab results, etc.).
- Issues Identification: Identify the client's health problems or nursing issues.
- Outcomes: Define what improvement or changes are expected in the client’s condition.
- Actions: List nursing interventions that will help achieve the outcomes.
- Evaluation: Assess whether the outcomes were met and adjust the plan as needed.

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How do I embed a care plan into an electronic health record (EHR)?

Many EHRs allow importing documents in specific formats. You can download the care plan as a PDF, Word document, or plain text and upload it into your EHR system. For specific instructions, consult your EHR software’s user guide.

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How do I evaluate whether a care plan is effective?

To evaluate effectiveness:
- Compare the client’s current status with the defined outcomes.
- Assess whether the actions were implemented as planned.
- Determine if adjustments are needed to improve results.

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How do I find a care plan for a specific condition?

Use the search bar on the CarePlan Library page to type the condition you’re looking for (e.g., diabetes, hypertension).

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How do I write a care plan?

Writing a care plan involves these steps: 1. Identify the client’s issues (e.g., ineffective airway clearance). 2. Determine measurable outcomes (e.g., client will maintain oxygen saturation above 95% within 48 hours). 3. Develop specific, evidence-based actions (e.g., administer oxygen as prescribed, monitor respiratory rate hourly). 4. Evaluate the outcomes and revise as necessary.

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Is there a fee to access care plans?

Yes. CarePlans.com membership is very inexpensive and can be cancelled anytime.

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What are the common challenges in writing a care plan?

Common challenges include:
- Lack of detailed assessment data: A strong care plan is based on thorough assessment.
- Unclear or unrealistic outcomes: Outcomes should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).
- Generic actions: Actions should be specific to the client’s condition rather than vague or general.
- Failure to evaluate and update: Care plans should be dynamic, adjusting as the client’s condition changes.

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What happens if a client does not meet the expected outcomes?

If outcomes are not met:
- Reassess the client’s condition for any new issues.
- Modify or adjust actions as needed.
- Consider if the outcomes were realistic given the client’s condition.

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What is a care plan?

A care plan is a structured, individualized approach to providing healthcare that outlines a client’s needs, desired outcomes, and the actions required to achieve those outcomes. It serves as a communication tool among healthcare providers, clients, and families.

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What is PDPM?

PDPM and Its Relation to MDS in Long-Term Care

PDPM, or the Patient-Driven Payment Model, is a reimbursement system implemented by the Centers for Medicare & Medicaid Services (CMS) for skilled nursing facilities (SNFs) under Medicare Part A, effective October 1, 2019. It replaced the Resource Utilization Group (RUG-IV) system and ties payments to patient characteristics and care needs, as documented in the Minimum Data Set (MDS) assessments.

Key Points about PDPM and MDS

  1. Purpose of PDPM:
    • Aligns Medicare payments with clinical complexity and resident needs, not service volume (e.g., therapy minutes).
    • Improves payment accuracy, reduces administrative burden, and encourages holistic care.
  2. Role of MDS in PDPM:
    • The MDS is a standardized tool collecting clinical data on diagnoses, functional status, cognitive status, and care needs.
    • MDS data drives reimbursement by determining case-mix classifications for payment components.
  3. PDPM Components:

    PDPM calculates reimbursement based on six components, each with case-mix groups derived from MDS data:

    • Physical Therapy (PT): Based on primary diagnosis, functional status (MDS Section GG), and cognitive status.
    • Occupational Therapy (OT): Similar to PT, using diagnosis, functional status, and cognitive status.
    • Speech-Language Pathology (SLP): Based on swallowing disorders, speech/language deficits, cognitive impairment, and diagnoses (e.g., stroke).
    • Nursing: Determined by clinical conditions, functional status, and nursing care needs (e.g., IV medications, wounds).
    • Non-Therapy Ancillary (NTA): Accounts for high-cost ancillary services (e.g., medications, supplies) based on comorbidities.
    • Non-Case-Mix: Fixed component for facility overhead, not tied to MDS clinical data.
  4. MDS Assessments Under PDPM:
    • 5-Day Assessment: Initial MDS within 8 days of Medicare Part A stay, sets payment rate.
    • Interim Payment Assessment (IPA): Optional if resident’s condition changes significantly, adjusting payment.
    • Discharge Assessment: Captures status at end of Medicare Part A stay.
    • Accurate coding of diagnoses (ICD-10), functional scores (Section GG), and comorbidities (Section I) is critical.
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  6. Impact on Long-Term Care:
    • Clinical Focus: Incentivizes focus on clinical needs and comorbidities, not therapy minutes.
    • Documentation: Requires precise MDS coding to avoid underpayment or audit risks.
    • Interdisciplinary Approach: Encourages collaboration among nursing, therapy, and medical staff.
  7. Key MDS Sections for PDPM:
    • Section GG: Functional abilities (mobility, self-care) influence PT, OT, and nursing.
    • Section I: Diagnoses and comorbidities drive PT, OT, SLP, and NTA rates.
    • Section O: Special treatments (e.g., ventilator care, IV medications) impact nursing and NTA.
    • Section C and B: Cognitive status (e.g., BIMS) affects SLP and other components.

Summary

PDPM uses MDS data to classify residents into case-mix groups determining Medicare Part A reimbursement for SNFs. The MDS captures clinical and functional data reflecting care needs. Accurate, timely, and comprehensive MDS assessments ensure appropriate payment and compliance.

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What is the difference between a care plan and a nursing diagnosis?

A care plan is a comprehensive document that includes multiple aspects of client care, while a nursing diagnosis (better referred to as a nursing issue in the CAT system) is a specific problem identified as part of the care plan. Care plans include outcomes and actions tailored to address these issues.

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What is the role of evidence-based practice (EBP) in care plans?

Care plans should be grounded in evidence-based practice, meaning actions should be based on the latest research and clinical guidelines. This enhances the quality and effectiveness of client care.

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What kind of videos are available in the Video Vault?

The Video Vault contains tutorials, recommended videos, and original content covering topics such as nursing procedures, client education, care plan writing, and professional development.

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What’s the difference between outcomes and actions?

Outcomes are the desired results or goals for the client (e.g., improved mobility). Actions are the steps taken to achieve those outcomes (e.g., assist with range-of-motion exercises twice daily).

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Who develops a care plan?

A care plan is typically developed by healthcare professionals such as nurses, doctors, or case managers, often in collaboration with the client and their family. In some cases, interdisciplinary teams contribute to its development.

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Why are care plans important?

Care plans ensure continuity of care, promote collaboration among healthcare providers, and keep care focused on the client’s specific needs and outcomes. They help identify priorities and streamline treatment.

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