Care plans
are not a favorite among most nurses. It's difficult to develop plans for someone that is hospitalized, and
you are unsure how things will go.
However, as time consuming as they are, they are an essential part of
nursing.
The Need
for a Care Plan
Care plans
are individualized plans specific to that patient. They are based on the exact needs of the
patient, and it coordinates with the patient's diagnoses, and their specific
needs. The care plan is designed to
inform the following shift exactly what is being done for and with the
patient. This is a way of communicating,
similar to a log book passed on from staff to staff.
Care Plan
Contents
In addition
to the communication aspect of a care plan, it should provide instructions so
that a nurse unfamiliar with the patient could step in and know what to
do. This would include special request
of family members or the patient themselves.
Care Plan
Guidelines
Care plans
must be completed for every patient that is hospitalized for more than 25 hours. Both Medicare and Medicaid require a care
plan in a detailed format for every patient. If the care plan calls for a nurse with a specialty skill, then the
patient will be assigned to a specific nurse for their expertise. Many insurance companies will deny payment if
the care plan is not put in place with adequate notes and a summary of the
patient's condition. There should be a
nursing diagnosis included. A nursing
diagnosis is not a medical diagnosis, but rather input from the nurse regarding
the patient's spirit, mood, if they are eating well, etc.
Care Plan
Example (daily note)
Mr. Blank was
feeling fairly well this evening. He
spoke of attending rehabilitation, therapy and did so with a positive
outlook. Mr. Blank ate about half of his
dinner, saying that he did not feel he could consume the rest. He later asks for a sandwich, and was able to
eat that. The patient was reading and
watched TV prior to going to bed. The
patient was nauseous around midnight and received medication which seemed to
help.
Care plans
benefit everyone that reads the patient's records. A social worker can read the care plan of a,
patient, and gain quite a bit of information prior to even meeting them. That can help to develop potential plan, and
allow the social worker to explore options and present them to the patient.
Care plans
can also help to track the patient's progress and outlook. Close observation of a patient's care plan
could indicate the need for counseling, as it can show levels of
depression. Some care plans have graphs
of charts that indicate the patient's mood, and this can help to determine if
there are needs for additional supports.
All
patients have medical charts, which are filled with information that is all
very detailed and specific. A medical
chart or record will provide any information that is pertinent to the patient's
health. Medical charts and notes are
very accurate and complete, plus now that they are electronic, they are more
helpful when a patient sees multiple doctors. There is no question, a medical chart is vital to the proper care of a
patient. A Care Plan can serve as the
more personal approach in some ways, it covers the patient's lifestyle. Before a chronically ill patient is released,
it must be determined that they have a safe place to go, and that they can
either care for themselves, or have others that can care for them. A care plan will provide input as to family
involvement with the patient, and more importantly, how does the patient feel
about being released, do they feel they are going to a safe environment.
A care plan
is an essential part of a patient's records, and should be kept updated as much
as medical records. If you are starting
a care plan for a patient, be sure to spend some time with the patient, and
actually get to know them before starting the care plan. Organize the care plan
so that anyone could look at it, and learn information about the patient. A care plan benefits the patient, and all
medical staff working with the patient.
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