Care Plan

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Learn how to write a patient care plan.

0:00 This short tutorial introduces you to the concept of writing patient-centered care plans.
0:08 Care plans describe the care services and support a patient will receive from his or her healthcare team.
0:15 They describe patient needs, necessary actions, and care responsibilities.
0:20 All care plans should be based upon a thorough assessment of the patient’s needs.
0:24 As such, information should be gathered from a variety of sources including the patient, the patient’s family members, and the medical professionals involved with patient care.
0:34 Most importantly, while the care plan ultimately serves many purposes, it should be written for the patient’s benefit.
0:41 Thus, they should be written in cooperation with the patient or the patient’s caregiver when possible, use language the patient and caregiver understand, and be formatted in a way that meets the patient and the caregiver’s needs.
0:55 The audience for a care plan will depend upon the particular situation of the patient.
0:59 For example, if the patient seeks medical attention for a relatively minor ailment, like a rash, he or she would be capable of undertaking a care plan and, as such, would be the target audience for the care plan.
1:12 If the patient suffers from something more severe that requires assistance from a caregiver, such as family, friends, a home health aide, and so forth, the care plan should be written with the caregiver in mind as the target audience.
1:25 In acute and chronic situations, such as when a patient is hospitalized or a resident in a long-term care facility, the care plan includes aspects related to health sciences professionals and nursing and medical staff members that may not be appropriate for a family member or friend.
1:44 A care plan should include information related to the rationale behind the plan.
1:49 In almost all cases, this will be directly related to the reason the patient sought care.
1:54 In addition to the initial purpose, the goal of the care plan is to help the patient achieve a specific outcome or set of outcomes.
2:01 As such, the care plan should be written with the outcomes in mind.
2:05 Care plans are grounded in evidence gathered from two points of view: subjective and objective.
2:11 Subjective information is what the patient and the family members state about the specific situation.
2:17 This aspect of the care plan is important because what the patient and his or her family believe to be true represents their perception of the overall context.
2:27 These thoughts and feelings must be acknowledged as part of the care plan.
2:31 Objective information is gathered from scholarly literature, experience, and collaboration with other health care professionals.
2:39 Though it won’t be written like an academic research paper, the care plan must present a synthesis of information that justifies the approach and guides the patient toward the intended outcomes.
2:51 Most formal care plans are written using simple, straightforward language that anyone can understand.
2:57 Present tense and active voice are strongly preferred because sentences written this way take on an action orientation.
3:05 Bulleted lists or numbered steps with lots of white space and internal headings help patients and caregivers move through the steps easily.
3:14 Be sure to consider the visual needs of your audience with respect to font style and size.
3:20 When writing specific bullet points, keep the NANDA International Nursing Diagnosis indicators in mind.
3:26 These diagnoses are developed by nurses with both nurses and patient care in mind, and as such, point healthcare professionals to additional information to consider, including potential related factors and risk factors, that may help the health care professional expand the care plan.
3:45 In addition, the Nursing Interventions Classification, or NIC, and the Nursing Outcomes Classification, or NOC, may be useful in providing specific courses of treatment and intended outcomes for NANDA diagnoses.
3:59 Take caution, however, in using NIC and NOC information verbatim as it may not be accessible to all audiences.
4:07 The example care plan you see here is very brief.
4:10 Many care plans will be significantly more extensive than this, but each should be carefully tailored to the patient’s actual needs.
4:17 Notice that the care plan is “you” focused, meaning that the language tells the patient exactly what he or she should do and expect.
Displayed on screen Links: Excelsior Online Writing Lab, Download a Transcript, Download a Tip Sheet with Examples

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