Enloe Medical Center Inpatient Nursing Care Planning Screen
We are currently redesigning our care planning screens for the *3rd* time. Our first version was out on the FTP site, but I asked Churton
to remove it, because I did NOT want to send people down the path that we went.
Version One was a "nursing only" care plan because only nursing was charting in Care Manager. It was relatively simple to use, because
it really wasn't problem oriented--it was more system oriented. Users selected ALL the pertinent CV problems in one result "CV problems",
but because that result was attached to a "status" category group(ongoing, new, potential, resolved) they could change the status of one
or more results......in theory. In practice, they may have "resolved" one problem, but they were not savvy enough to de-select it from the
"ongoing". So it showed up as both ongoing AND resolved. There was one "plan of care" result, but there was no way to link any choice in
the plan to a specific problem in the problem list. The same situation existed with the expected outcome result. However, our nurses liked
the screen and they were actively "care planning" their little hearts out. It just really didn't make any sense.
Shortly before our JCAHO visit last spring (and I mean shortly, like 6 weeks before), the hospital decided that we needed a
multidisciplinary approach to care planning. A group of representatives from different patient care disciplines met and came up with a
different approach:
In Version Two we decided that we needed to go to a more problem-specific mode of charting. But we also were under the impression
that all disciplines should be sharing the same *charting* form (a mistaken impression, as it turns out--all disciplines just need to be able
to see the entire plan of care, either online or via a printed report). Because the problem list was going to be huge we organized it by
body systems. Users would open the "Neuro problems" class and get a clustered category list of problems. Once they picked a problem
they could assign it a status and then chart the appropriate plan of care (Nursing plan, RT plan, RD plan, etc) and then the expected
outcome. The *theory* was that only Nurses would initiate or modify a nursing care plan, only RT should initiate or modify an RT care
plan, etc. In reality nursing staff cheerfully change the dietitian's (or RT's or anyone else's) plan of care. The other drawback to this
version was that each class (such as "Neuro problems") had ONE clustered category group of problems, which meant that not all plans of
care or all expected outcomes were pertinent to all problems in the list. But, because we had to have POC's and EO's for every problem,
the list of legends in each one of those results was very large. Another disadvantage was that using body specific class lists caused some
redundancy of problems--a patient could have SOB related to a cardiac reason OR a pulmonary one. So sometimes a patient would have
TWO SOB problems in their care plan. Version two allowed us to have problem-specific care plans (good) but the charting screen was
difficult to navigate through and the information was not really usable.
Now, the BIGGEST flaw in both of these versions was our use of Last Entry.
Once again, in theory, it made sense to have people pull the care plan forward and review it or modify it. It keeps the care plan up to
date and demonstrates that staff have been actively planning the care of the patient. How did it not work? Let me count the ways:
Our initial expectation was that people would "Select All/Last Entry" and then pull "Most recent session". On the very first day
of the care plan go live, we had people just waltzing in and doing their OWN thing, completely ignoring what others had entered
before them. So, the next person to pull up the "most recent session" would get only the "rogue" session and the previous care
planning was lost (not to the report, of course, just to the users trying to do what we told them to do).
So we changed our instructions and told them to use "most recent charting". In that way, both the rogue care plan and the
previous care planning would be pulled forward (unless the rogue charting superceded the earlier stuff). Sounds good? NO!!
What happens if an inaccurate entry was removed on the last charting session--not changed, but cleared? Well, the next
person who brings "most recent charting" forward then re-creates the inaccuracy. And, since most of the staff were not
actually reading the care plan (yeah, yeah, yeah...you mean I have to actually read this??) the inaccuracy wasn't being
corrected.
And then there were the staff members who chose to annotate one-time interventions--Lasix 20mg IV given...and that gets
pulled forward, time after time after time.
We were so good at getting people to do their care plans that if they didn't finish them during yesterday's shift, they back-timed
and care planned today for yesterday.
Because it was relatively easy to use last entry, the problem list would get bigger and bigger, but not necessarily BETTER.
Lastly, the resulting discharge report was HUGE. We had a patient discharged after 4 months and his care plan was 178 pages
long!
So, now we are on Version Three. Our redesign committee has come up with a template that we like:
Each discipline has its own care planning screen (eliminates clutter, makes it easier to navigate). Online reviews can reflect
everyone's charting.
One class: Care Plan
Problem-specific, however the problems start out relatively broad, and funnel down to specifics. This limits the numbers of
problems that our overzealous users can select, while at the same time giving them the opportunity to address all the
contributing factors. Each plan of care and expected outcome is built for that problem. So, it's a big build on the FSB side, but
makes a LOT more sense for the users. For example:
Alt bowel elim -> -> Related to (constipation, diarrhea, colitis, gastric bypass, etc. Users can pick more than one)
Status (active, potential, resolved--exclusive legend)
Expected outcome (soft formed stool, estab regularity, etc. Users can pick more than one)
Nursing plan (encourage fluids, encourage hi fiber, ambulate, etc. Users can pick more than one)
A problem is only entered ONCE and is not touched again unless it is modified or resolved. Last Entry is NOT used.
Users have a result at the top of the Care Plan class ""CarePlan reviewd" (autolegend=yes). This result is configured into its
own class for the discharge report only, and it wraps. This takes up the least amount of space.
The care plan review only displays problems (not the ""CarePlan reviewd" result). The review is configured to show 30 days, so
that it will show only those blocks of time in which a problem was initiated or modified.
Our committee debated how users would best see the care plan. We honestly don't feel that viewing it online would be
particularly useful. We have decided that the care plan will print daily. It will not contain the "CarePlan reviewd" result. The
report will be configured to a 30 day time span, so that active problems will display without the need to use Last Entry to pull
them forward. Our goal is that users will use the care plan as the basis for their shift to shift report and that they will hand the
care plan to the oncoming shift. If a care plan is updated, the user will be responsible for printing it out.
Staff education will be a MUST. Our users need to be encouraged to keep it short and sweet and realistic. They should be
picking choices that are reflected in their documentation. They should be considering this as a form of communication to the
next shifts.
The online review would contain a Nursing Care Plan class, an RT care plan class, etc. We haven't decided yet whether the
daily printed report might just be the Nursing portion of the care plan. On one hand, nurses are responsible to oversee the plan
of care, but realistically, what we should alter is our own plan of care, not what others have planned. This is still to be
determined.