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?
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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?
I don't! :p
Don't use care plans in the ER... :banana:
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
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
We have initial ones, too and are done by hand.
Our care plans are printed checklists.
My care plans are hand written.
Fun, ain't it?!Quote:
Originally Posted by dustinscott
Since my last post, we're all electronic now and the care plan feature of the program is garbage. Yeah, it works but like ther rest of the program(s) all rolled into one giant electronic mess, is not intuitive. It's a good thing that our IT department is so large because they have to be in order to keep the system propped up.
I know this thread is a month or so old but I thought I'd share :). Used to do written/checklist care plans and now we do most of them electronically, takes most of the time out of each to be honest and a lot of automatic referrals are done with the care plan. It makes life a lot easier that's for sure.
We do have written careplans..hopefully our facility can already make upgrade for us to use computerized care plans like what others are mentioning in here. I think it’s much more convenient as it will be easier to update as the patient conditions changes!
Only saw care plans used at one facility (LTC). After a change in management, new generic care plans were added to the charts for each resident. After that, most of the staff nurses ignored them.