Care Plan Or Planning Of Care?

Revisions of nursing standards created questions regarding the necessity of nursing care plans. Some have predicted the rapid demise of the care plan, according to Brider, but review of the revised nursing standards shows that the standards require not less but more detailed care planning documentation in the patient’s medical record.

Review of the new criteria indicates that the standards require documentation related to the nursing process. For example, the plan of care statement reads:

A plan, based on data gathering during patient assessment, that identifies the patient’s care needs, tests the strategy for providing services to meet those needs, documents treatment goals or objectives, outlines the criteria for terminating specified interventions, and documents the individual’s progress in meeting specified goals and objectives. The format of the “plan” in some organizations may be guided by patient-specific policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these. The plan of care may include care, treatment, habilitation and rehabilitation.

Rather than eliminating care plans, the requirements call for a more specific as well as a more permanent documentation of the plan of care. This documentation must be in the medical record. The standard indicates that a separate care plan form is no longer necessary; however, the standard also still allows a separate care plan form. Various institutions are now testing flexible ways of documenting care planning. The care plan is not dead; rather, it is revised to more clearly reflect the important role of nursing in the patient’s care. No longer a separate, often discarded, and irrelevant page, the plan of care must be part of the permanent record. The flow sheets developed for this book offer guidelines for computerizing information regarding nursing care.

Faculty can use the revised standards to assist students in developing expertise beyond writing extensive nursing care plans. This additional expertise requires the new graduate to integrate all phases of the nursing process into the permanent record. Rather than eliminating the need for care planning and nursing diagnosis, the standards have reinforced the importance of nursing care and nursing diagnosis.