Care Plan

Care Plan

Why do I have to write so many care plans?

The purpose of students creating care plans is to assist them in pulling information from many different scientific disciplines as they learn to think critically and use the nursing process to problem solve. As a nursing student writes more plans, the skills for thinking and processing information like a professional nurse become more effectively ingrained in their practice. (RN Central, 2017)

Purpose:

  • Individualised care for patients
  • Guide staff in assisting the patient
  • Improve consistency of care across various healthcare professionals
  • May be used for reimbursement/payment of services through Medicare and Health Insurance

Content and Format:

  • The exact format can vary at different facilities.
  • Generally they need these five areas: nursing diagnoses (actual and potential), goal(s), interventions, rationale and evaluation/outcomes.
  • Once on-the-job, your care plans will be supervised by an RN.

Structure:

  • Often a care plan will be written or filled out in a table like the example below.
  • Make sure that the diagnoses, interventions and rationale all align logically and clearly.

Nursing Diagnosis

Issues/Problems

Goals

Interventions

Rationale

Evaluation

(what is reviewed, what tool will you use to make sure goals are met)

 

 

 

Referencing

  • References are needed in care plans that you complete for assessments so your Educator knows where your information comes from.
  • They are not usually included in on-the-job care plans.