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The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
A simplification of the main aspects of a management system is the 4-element "plan, do, check, act" approach. A complete management system covers every aspect of management and focuses on supporting the performance management to achieve the objectives. The management system should be subject to continuous improvement as the organization learns.
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
The plan–do–check–act cycle is an example of a continual improvement process. The PDCA (plan, do, check, act) or (plan, do, check, adjust) cycle supports continuous improvement and kaizen. It provides a process for improvement which can be used since the early design (planning) stage of any process, system, product or service.
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The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and ...