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Creating Care Plans that serve the patient and charts that are representative of patient condition
Susan Collins, RN FN
Where to begin?
Patients usually enter the healthcare system with an illness or injury Patients using the CAM model may access healthcare more often for wellness and prevention initiatives. How ever a patient enters the system at a given time, the plan of care for them in the patient centered care model is based on meeting their needs.
SOAP Format
Patient assessments are found with various catchy titles. The basic one is the SOAP format. It is most often used in charting, and sometimes even with the letters out to the side. It is so well understood that no one wonders what is that? SOAP format helps in creating care plans by identifying patient needs.
Subjective
S=Subjective : What do you hear the patient, or subject, saying about what is happening?
Example: I can always tell when my blood pressure is up, I get the worst headaches.
Objective
What does the nurse see happening at the time that relates to the problem?
Ex: Patient noted to be holding her forehead when observed upon admission. Ex: Wound drainage purulent. Ex: Face flushed and patient observed picking at her sheet.
Assessment
What the nurse or caregiver does to investigate the complaint or complete an ongoing assessment of the problem. How is this situation evaluated?
Ex: Take BP every 4 hours and PRN c/o headache Ex: Check dressing q2h and redress PRN
Plan
The plan is exactly as you suspect, what is the plan to help this patient? Example: If a patient has asthma, then a Ventolin rescue inhaler should be administered when symptoms occur or before exertion. May include short and long term actions
intervention
measures you have taken to achieve expected outcomes.
Ex. Patient with CHF experiences ankle edema after sitting up in the chair for the afternoon, so an appropriate intervention would be provide a period of rest with his feet elevated for 30 minutes after sitting.
evaluation
Analysis of the effectiveness of your interventions. Did the patients ankle edema decrease after elevation?
revision
Changes from the original care plan that could more effectively benefit the patient. EX: have the patient limit sitting up in a chair to 45 minutes, followed by elevation of the lower extremities.
Care Plan pt II
Establish an intervention to help achieve the goal
Instruct patient in interpreting food labels. Inform patient about fiber Instruct patient in how to deduct fiber from carb count Assist patient in establishing a format for recording carb intake
View It
http://www.youtube.com/watch?v=nSbdPJzxX0 Nursing School: Nursing Care Plans hdryver
Try It!
Using the template provided, fill in a sample care plan for a problem using the assigned disease.
Plan It!
Care plans and charts are vital ways that all areas of healthcare providers communicate for the safety and benefit of the patient! Be accurate, concise, tidy, and impartial in your notes and plans