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A care plan is a legal document that contains an assessment of a patient’s needs and details the level of care that he/she should receive. It is used to coordinate the care given to the patient by different members of the health care team. Care plans may be printed on paper or created electronically.
Today, about 85.9% of office-based physicians in the United States utilize an electronic health record system. With this form of medical record-keeping, you may create your own care plan template design and then incorporate it into the electronic system to help track and record all aspects of patient care management.
If you believe that designing an independent care plan template for your own practice or institution, this short guide is for you. Here, we list down the top components of an effective basic plan. Read and study them all so that you can provide comprehensive care for all your patients.
The first essential component of a care plan is the Assessment section. This is where you write down the patient’s medical and surgical history, signs and symptoms, and any relevant diagnostic test result.
Most care plans are created by the nurses in accordance with the different medical, surgical, and mental diagnoses and treatment plans developed by other members of the healthcare team. If you are creating a nursing plan, your diagnosis should be based on the NANDA (North American Nursing Diagnosis Association) classification system.
Other types of care plans may not follow the NANDA system and may just write down a general diagnosis based on the patient’s symptoms. Emergency healthcare plans, for example, will usually include the most common emergency conditions and provide a list of treatments that anyone can do to treat an individual suffering from such condition.
Another essential component of an effective care plan is, of course, it’s a proposed plan of care. In this section, write SMART goals.
For example, if you are making a home health care plan for a bed-ridden patient, your recommended list of actions may be to turn the patient sideways every two hours to prevent bedsores. Consult a care management textbook or online source for a more reliable, accurate, and advanced plan of care.
This is the portion where the provider implements his/her action plan. This can involve patient education, health teaching, and different caring techniques from physically assisting the patient to routinely monitoring the patient’s status.
All action taken should lead to the alleviation of or the total disappearance of the symptoms that the patient is experiencing.
Unlike other kinds of plans, care plans will have designated sections where other members of the healthcare team can write down the results of the different measures done to care for the patient. This allows you and the healthcare team to know if your printable plan of care was effective or not and lets you come up with an improved plan of care.