Using Care Plans
Some institutions forgo formal written care plans because of staff shortages and time constraints — until time for surveys. Others use them in varied forms from simple and barely complete, to something your professors would hail as an “A” paper.
The fact is that whether you have a formal written plan, as you use the nursing process to deliver your care, you will formulate a care plan for each of your patients. Each time you perform a nursing intervention you will have goals for your patient's outcomes and will assess the response to the intervention.
Care plans provide a road map for the entire team to follow in providing care. These plans also provide evidence of where you have been and what worked and what didn't. If a problem has been resolved, it is crucial for the team to know it and move on. Valuable time can be lost continuing to focus on an issue that is no longer important.
Some regard care plans as a waste of time, but actually, if used properly, they can be a time saver. Each shift doesn't have to reinvent the wheel. Perhaps issues have been reprioritized because of some changes; the care plan disseminates this information to the team. Without some form of formal plan, the continuity of care is compromised and the quality of care and outcomes are no longer optimal.
Care plans are an important part of the health care delivery process and should be utilized. This is more important now as the delivery system shifts away from primary care back to a system used in the 1970s and early 1980s where R.N.s were team leaders and LPNs and aides provided most of the hands-on care. Today as more and more unlicensed personnel are used, the level of responsibility on the R.N. is compounded and a road map for the care is even more essential to keeping everyone on the same page.