Creating the Care Plan. PCS Lesson Five. OBJECTIVES. Following completion of this lesson you will be able to: Demonstrate how to select a care plan Identify the parts of the care plan Demonstrate how to tailor the care plan to the patient’s needs
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
PCS Lesson Five
Following completion of this lesson you will be able to:
Collecting assessment information allowed you to discover more about this patient’s individual needs for care while a patient at GBMC. Creating a care plan will provide you with a list of nursing problems and a measurable set of desired outcomes with associated target dates.
Developing the patient’s care plan is the next logical step in the admission process. Later you will monitor the patient’s progress and adjust the care plan as needed to move the patient towards discharge.
In this lesson you will create a care plan and edit it to add what is missing and take away what does not belong. You will learn how to customize the care plan to perfectly match the patient’s individual condition.
The outcomes are the goals you will strive to reach in order to resolve the problem during the patient’s stay.
programmed target date. This target date represents the date that it is
expected the problem should be resolved. It is important to advance
the target date if the patient has not met the expected outcome by the
designated target date.
We want to prioritize our problems, so we will click on the Prioritize Problems option.
1. Select the plan.
2. Delete the problems that do not apply.
3. Add any additional problems your patient is having.
4. Assign a priority to problems that were added to the care plan.
5. Save the plan.
The next column is the text column. You can click in the text column to add or edit text attached to an Outcome. Remember that any text you add will become a part of the patient’s permanent medical record, so we only want to use this feature for professional communications.
The first thing we notice is that one problem we added does not have a target date. Before we can document on this outcome, we need to give it a target date. All we need to do is click in the blank space in the target date column. Let’s do that now.
There are guidelines listed in the answer box in blue text to help you determine whether the outcome has been met. This patient’s pain outcome, according to these objectives, has not been met. We will document that now by clicking on the Not Met selection.
The holistic Plan of Care consists of Standards of Care interventions, the care plan, and nursing orders.
To choose a care plan or add additional problems to a Care Plan, click on Process Plan from the Status Board.
Select a plan based on the type of patient admission, individualizing the plan by adding and deleting problems as needed.
Assign a priority to new problems and organize preset priorities based upon your analysis of the patient’s needs.
Document Outcomes at least every 12 hours.
Every outcome must have a Target Date which you define.
Correct errors in outcome documentation using the History column.