Today, home health nurses spends more time in the electronic medical record than taking care of the patient. Nursing care plans seem more about the process than the patient. This is why the care plan is more a formality than a usable tool that guides nursing practice. Let’s look at getting back to a patient-centered care plan that makes sense for meeting patient goals and functional outcomes.
Before The EMR:
Let’s look back at what nursing care looked like before the EMR. Agencies had a 485 with basic interventions and goals written to address safety and well-being for the patient in the home. Nurses wrote interventions related to meds, diet, and disease process. Goals addressed the patient knowledge base and meeting expected physical outcomes. We are talking about a couple interventions for each target category and a goal for each. If the patient would continue to subsequent cert periods, care plans addressed the main issue for each cert. The nurse looked at what was expected for the patient and how many nursing visits were needed to complete the desired outcomes. Documentation was not overwhelming, but it was clear what the nurse did when she walked in and out the door. The nurse did the physical assessment, documented the findings on a flow sheet along with the interventions and outcomes, and documented a narrative regarding the skilled nature of the visit. That was really it.
Looking At The Care Plan Today:
The evolution of the EMR allowed nurses to click on multiple interventions for every body system, diagnosis, and made clinical pathways in a click. Here’s the issue. This made 485s five or six pages long. Meanwhile, nursing orders are listed as one time per week for nine or ten weeks. Reality is that no one is going to be able to complete all of that. All the while, no one has really consulted the patient on what is on that care plan. Yes, we know that agencies document the patient is agreeable to the care plan and they are given a copy. The question is: How much is really relevant for them? Did they have anything to do with putting the plan together? How many items listed that will resolve as anticipated on their own without your direct intervention?
Yes, we realize the complexity of the care plan is partially due to the evolution of regulations such as emergency preparedness planning for each patient. These are things that cannot be avoided. However, the actual care plan has become irrelevant to the nurse actually planning her care for the visit. We have gotten so lost in the sea of data that nurses cannot take the time to review care plans and previous visits in a meaningful way. Therefore, most nurses walk into the homes without a true road map as to what is next for the patient. If the nurse can’t do this, then how is care truly patient-centered? The nurse doesn’t know what the patient wants to accomplish unless she has been the only person to see the patient throughout the entire course of care.
Getting Back To Basics:
Consider how many canned interventions are overkill in your EMR. Eliminate the majority. The nurses always have the ability to type an individualized intervention. Getting nurses back to making a focused care plan as opposed to clicking twenty-five interventions for what can be said in three is key to moving forward. This means less time in documenting and makes the care plan easier to document against. Consider a focused clinical note that makes it easy for any nurse to know how far the patient has advances towards care plan goals. Make the patient the focus. Every visit should have something to address what the patient thinks is missing from care or where the patient needs more focus to accomplish the next milestone in recovery. In the majority of agency documentation we see, this is missing.
Let Us Help You Change How You See Your Care Plan:
Nurses will be a little uneasy about this process if it is not addressed properly. For years, more and more has been added and agencies have said that so many things must be documented. So, it is important to approach documentation changes systematically. At Kenyon Homecare Consulting, we focus on helping agencies provide high-quality care. Call us today at 206-721-5091 or contact us online and let us help you change your care planning process to something that works for the nurse, patient, and the agency!