How do YOU do your care plans?!

[cougarnurse]

Just wondering how the rest of you do your Care Plans. Are they hand written? Computerized? And how do you update them with either way written?

[AmandaWIRN]

I don't!


Don't use care plans in the ER... :banana:

[nursinghumor]

Initial ones on admission are usually hand written and updated.

Several facilities I work for have computer databases. They print them out and cross out or write in as applicable to the patient.

Andrew Lopez, RN
http://www.nursefriendly.com

[Ricu]

We have the MOST inefficient documentation process in the entire universe! The cornerstone of our daily recording is the traditional, hand written, critical care flowsheet. Computer geeks call it old fashioned but we can lay our hands on every bit of essential data in one place and the physicians only use this. Because double documentation is much safer than single documentation (not), we also have a computer based "care plan" which is hopelessly redundant and slow. While the shift assessment section is part of the same database, the user cannot flow from one to the next but must back out to the main menu. Lab reporting is also on this mainframe but like the assessment program, must be accessed from the main menu. As you can see, documentation is very tedious and time consuming for us. To add insult to injury, nobody even reads this online data because it's so hard to visualize. This has all been a staged build keeping the IT department very busy. I think there are more IT staff at our hospital than clinical staff. We're getting Sorian which will be going live in a few weeks. I've never seen it but been told by the "super users" that it's a great program. It can be mediocre and still much better than the crap we use now. I don't know, maybe that's been the strategy all along...

R

[Grandma-RN]

We have initial ones, too and are done by hand.

[Mayrill]

Our care plans are printed checklists.