TITLE: GUIDELINE FOR THE PLAN OF CARE, MR #434

INSTRUCTIONS:

1. Place patient's identification sticker in the upper left hand corner.
2. Date the first column with the date of the initial assessment.
3. Record each protocol that is to be used to provide nursing care for the patient following the initial admission assessment by an RN.
4. Place an up arrow (?) in the Date column and the time the protocol was initiated (?1340).
5. Daily assess the plan of care. If a protocol is continued place an arrow in the next date column (?).
6. When a protocol's outcomes are met, dc the protocol by placing the date the outcome was met and a down arrow in the date column (?1045).
7. The nurse caring for the patient initials at the bottom of the date column after the Daily Plan of Care is reviewed.
8. As additional protocols are needed to provide care to the patient, list that protocol and fill in the correct date column.
9. After 7 days, copy over all protocols still active on the bottom half of the form.
10. If the patient is still in the hospital at the end of 14 days, begin a new Daily Plan of Care sheet.

RESOURCE PERSON(S): Candy Conners, BSN; Carol Cox, MPH; Jo Ellen Austin, PharmD

Back to Guidelines Table of Contents
Home