The Purpose of the Written Care Plan
* Care plans provide direction for individualized care of the client. A care plan flows from each patient's unique list of diagnoses and should be organized by the individual's specific needs. * Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient's needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds. * Care plans help teach documentation. The care plan should specifically outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. * They serve as a guide for assigning staff to care for the client. There may be aspects of the patient's care that need to be assigned to team members with specific skills. * Care plans serve as a guide for reimbursement. Medicare and Medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented. The purpose of students creating care plans is to assist them in pulling information from many different scientific disciplines as they learn to think critically and use the nursing process to problem solve. As a nursing student writes more plans, the skills for thinking and processing information like a professional nurse become more effectively ingrained in their practice.
Care Plan Formats
The exact format for a nursing care plan varies slightly from place to place. They are generally organized by four categories: nursing diagnoses or problem list; goals and outcome criteria; nursing orders; and evaluation. As defined by the North American...
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