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STAT (Staff Training and Assessment Tool): Plan of Care/Care Plan/RN Care

STAT (Staff Training and Assessment Tool): Plan of Care/Care Plan/RN Care - Clinical Hub, Nursing Hub, Nursing Practice Tools and Resources, Resources


Q: How do you know the patient's Plan of Care?
A: I look in the patient's record. The Plan of Care is the entire
record. This includes things such as the MAR, notes, test
results, orders, and the Problem List. I also talk to other
members on the patient care team and look on the white
board in the patient's room.
Q: What is the Care Plan?
A:The Care Plan is a tool that all disciplines can use to review
and document the patient’s care. It’s the best place to go to
find documentation from many disciplines and to see how
each is contributing to the plan of care.
Q: Where can you find the Care Plan?
A: It is the first thing that opens when you go into the patient's
record.
Q: What is RN Care?
A: RN Care is the activity used by nurses to create and track
nursing plans of care. Not all disciplines see the RN Care
activity, but all information entered there is displayed in the
Nursing tab of the Care Plan.
Q: When do you need to document on the Care Plan and RN
Care?
A: Within 4 hours of admission and at least once daily.
Q: How is the patient and family included in planning care?
A: We include the patient and family in multiple ways:
• We include patients and families during bedside report
handoff at the change of shift.
• Care Team Visits are done at the bedside, giving patients a
chance to ask questions and share their thoughts and
concerns. This includes discussing their goals and plan for the
day and for discharge.
• We communicate with the patient and family and include
them in planning care by using the white boards in the patient
rooms.
Send completed forms to _________________ by ____________ (date).
STAT (Staff Training and Assessment Tool)
TOPIC: Plan of Care/Care Plan/RN Care
CORRECT RESPONSE?
Location/Unit: DATE/TIME/SHIFT:
Facilitator/Coach (Name/Title) Number of Participants:
Questions/Answers Action Taken and/or Comments
Survey Readiness Resource
Without
Coaching
With
Coaching
Updated October 2017 Page 1 of 1