Findings85 collected from the multiple methods in the pilot study helped discover some technology issues that were not always clear to our nurses and that allowed us to implement remedies. And while our method improved compliance and satisfaction with healthcare planning documentation, it did little to promote the collective spirit of the physicians involved in healthcare. We even found that many of the individual nurses have updated religiously and mentally updated care plans separately. Nurses rarely used plans to guide the transfer of information from physician to physician. In retrospect, this finding was understandable and repeated the evidence discussed in this chapter that plans in daily practice have generally yielded little value. Nurses are unlikely to use plans more patient-oriented rather than document-oriented, without informing them of how this could be done, to achieve the desired change.
We will also describe best practices to consider and give you an example of the nursing plan that you can download and print. According to evaluation and diagnosis, the nurse sets measurable and achievable short and long-term goals for the patient. Assessment, diagnosis and target data are written in the patient care plan so that nurses and other health professionals nursing essay topics who care for the patient have access to it. Unlike most electronic health record systems, nursing care plans are designed to meet the patient’s holistic needs, contributing to better patient experience. If all members of a care team have access to all information about a patient’s needs and preferences, they will all remain on the same page.
This work is documented in the EPD and the physician completes the action plan where the clinical assistant was stopped. While literature lacks generalization in this area, there are some nursing management important implications that can be drawn. First, the enormous variability in documentation and healthcare planning practices described in this literature is a serious problem in itself.
Nurses should use their knowledge, experience, resources, evidence-based practical research, advice from others and critical thinking skills to decide which nursing interventions would best benefit a specific patient. Nursing care plans and computer programs are available with generic nursing interventions for various problems and diagnoses, but these should be individualized for specific patients adapted to their situation. Nursing interventions are the real treatments and actions that are performed to help the patient achieve the goals set for them. The nurse uses her knowledge, experience and critical thinking skills to decide which interventions will best help the patient. Effective troubleshooting emphasizes the patient’s focus and prevents the doctor from imposing goals and plans on the patient. “Building a Collaborative Care Plan” presents the steps in setting goals and developing the action plan with advice, proposed questions and examples of patient answers.
There are currently 188 nursing diagnoses for which NANDA has defined and given related factors and defined characteristics. What you need to do is get this information to help you write care plans to diagnose your patients correctly. Care plans by their nature document every aspect of patient care, from evaluation to diagnosis, planned interventions, results and evaluation. This documentation helps other non-doctors (social workers, family members, administrators, trainees, etc.) know what happens to that patient and document what has been done and what has not been done. This system of checks and balances protects patients, nurses and other members of the interdisciplinary care team.