Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Without a specific document delineating the plan of care, important issues are likely to be neglected. Care planning provides a "road map" of sorts, to guide all who are involved with a patient/resident's care. The care plan has long been associated with nursing, and many people believe (inaccurately, in my opinion) that is the sole domain of nurses. This view is damaging to all members of the interdisciplinary team, as it shortchanges the non-nursing contributors while overloading the nursing staff. To be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of this patient/resident.
The first step in care planning is accurate and comprehensive assessment. In the acute care setting, a thorough admission nursing assessment should be followed by regular reassessments as often as the patient's status demands. In the long- term care setting, the MDS (Minimum Data Set) is the starting point for assessment. Home health utilizes the OASIS assessment. Other settings will have established protocols for initial assessments and ongoing reevaluation.
Once the initial assessment is completed, a problem list should be generated. This may be as simple as a list of medical diagnoses, or may involve working through the RAP (Resident Assessment Protocol) process associated with the MDS. The "problem" list may actually include patient/resident strengths as well as family/relationship problems, which are affecting the person's overall well-being.
Once the problem list is complete, look at each problem and ask the question, "Will this problem get better?" (Or, "Can we make this problem better?") If the answer is yes, then your goal will be for the problem to resolve or show signs of improvement within the review period. In the acute setting, the review period may be as short as next shift, next day or next week. In the long-term or home health setting, the review period will likely be longer. In any case, the goal should be specific, measurable and attainable. Do not write a goal that a stage 4 pressure ulcer "will be improved by next week." This is not specific or measurable, and most likely not attainable. A better goal statement would be for "stage 4 pressure ulcer to improve to less than full thickness and length/width to __X__cm in the next 90 days." The approaches (or interventions) should also be measurable and realistic, and should be documented elsewhere in the record when performed. An example of a problem that will improve would be self-care deficit related to hip fracture. With rehab, this problem is likely to resolve.
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