How are nursing care plans done in the work place? Is it computerized or hand writtten? Detailed or goes by a template? I think the kind we need to write for school is way to detailed and at times meaningless. What is the importance of a nursing care plan? I just want some personal opinions on how you find them useful/helpful/good or bad/unnecessary… etc.
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I’m a registered nurse in the UK, nursing care plans are hand written, health care assistants can write in them but a counter signature is required by the trained nurse, we write everything in their, how the patients wash (by themselves or with help) what the doctors say on their ward round or what OT or physios say, is the patient has refused meds, or any care that has to be wrote down, as this is classed as a legal document, for example a patient could refuse medication but then say you haven’t given to him, so if it’s wrote down theirs proof whats happened, we need it to cover our own back.
There’s also fluid charts in the care plan, food charts if a patient has seizures there’s fit chats, drug chats.
I’m a nursing student too. I think that the main reason that we have to write so many NCPs in school is so that we will learn to think like a nurse. In a real hospital setting, there are standard plans of care used. They may be computerized or written out, but as a nurse (in the U.S. at least), you should never have to sit down and write that you are going to check your patient’s vitals every 4 hours because they are at risk for infection!
Whenever I am doing my clinicals, I will ask for the hospital’s plans of care for different conditions. I have saved these and they are SO helpful when doing my own care plans!
We use a system that uses a prepared plans, either by medical diagnosis or by the more general nursing diagnosis. We then modify the plan to meet the needs of the patient. If you do not learn to write nursing plans in school, I don’t see how you could know how to use one when you get to work, and you will have to use a care plan, because without it you are just taking your best guess at the moment on what you want to do. Writing a care plan really forces you to ask what is wrong, how do I know, how can I fix it, what does fixed look like so that I am sure what I did worked (and if doesn’t work, I start doing something else)
I hated care plans. I don’t have time with 8 fresh postsurg patients to go to the bathroom, let alone write a care plan..but, that is not the fault of the care plan. that is the failure of the system. I can tell the new grads that don’t yet “think like a nurse” and the care plan is the most important step in learning how to do that.