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Fluff and Stuff

There are many reasons to write a thorough and complete care plan but thorough and complete doesn’t always equate to long. This is especially true where orders are concerned. There exists an overly cautious attitude among some nurses that drives them to include every possible order and intervention that the patient may ever need in this lifetime or the next. The end result is a six page document with crucial information buried between the ‘fluff and stuff’.

Here are some orders I see that make me wonder how they ever hit the care plan.

  1. Draw Lab per MD Orders. Why put that in your orders unless you have orders? If you have orders, simply write them. If you do not, then you will when you get the orders. Who else besides the MD would write lab orders?
  2. Teach Diabetic Care including use of glucometer, diabetic foot care, sick day care, rotation of insulin sites, diabetic diet, importance of Hemoglobin A1C, causes of diabetes, importance of exercise and rest, signs and symptoms of hyper/hypoglycemia to report to MD and SN and to report blood glucose levels greater than 300 or less than 50. That is the abbreviated version. It is my opinion that if we include in orders to teach Diabetes care, a responsible, educated nurse acting according to best practices will include all aspects of diabetic care relevant to the patient during the episode. Notice the reporting parameters are buried at the end of the order, easily missed or difficult to locate. The worst part of this order is that it is a daunting task to perform in a single episode assuming the patient has comorbidities. Our patients are not enrolling in nursing school. It seems to me that the nurse who wrote this order didn’t consider assessment data and limit orders to the patient specific needs.
  3. Weigh patient weekly. Generally speaking, this is a good order for a CHF or renal patient. It only becomes a problem when the patient isn’t seen but once every other week. A better order is to weigh the patient each visit and to teach the patient to weigh self on days between visits.
  4. Report weight gain of 3-5 pounds. Which is it? Three pounds? Five? If I were playing semantics, I could argue that the only weight between three and five pounds is four pounds. But, surveyors do not enjoy word games as much as I do. A better order is to report weight gain of greater than X pounds with X being determined by the original weight of the patient, the stage of heart failure and prior history.
  5. Report weight gain of greater than X pounds. While this is decidedly a better order than one with a range it is still not perfect. Consider my client who called me crying. Like me, she was an old Cardiac Intensive Care nurse. Her patient had strict parameters to call for a weight gain of three or more pounds in one week. Over the course of the episode, the patient put on one or two pounds a week. When the patient was admitted to the hospital, the patient had gained over 15 pounds. By placing the baseline weight on the care plan near the parameters, the nurses have additional information to make decisions. Additionally, a weight chart posted near the patient scale will show trends.

I like clear and concise orders. But truthfully, what I like is really not important. What is important is that our care plans are useful documents for guiding the care of nurses taking care of patients. Even surveyors can’t top that reason for writing clear, concise and individualized care plans.

As always, your comments are welcome below. Any other orders you find useless and can add to my list will help both me and your colleagues.

4 Comments Post a comment
  1. Millicent #

    Oh that I could get a penny for each time Ihave told nurses(at all levels) what you have reiterated about documentation. I would be independently wealthy now!
    Thanks for keeping the light shining on appropriate documentation.

    August 19, 2010

  2. You’re welcome! Thank you for your kind words. Most nurses spend their whole careers without ever having to worry about their license, etc. Those who are faced with revocation are never the ones who deserve it! But most of them charted something just a little less than accurate.

    August 19, 2010

  3. As RN Clinical Manager Performance Improvement, I review approx. 1/2 of all oasis assessments every month. A documentation issue that I find useless is in the goal section. Our nurses used to like to write goal to be met within “cert” period of time. I always have them change the goals met time period to the time frame they are actually planning on being in with the patient using the pre-determined frequency. An example would be if the frequency is 3w3; 2w2; 1w1 then all goals should be met within 6 weeks period of time. Most are just confused by this until I explain my reasoning. Now, I find most of our staff just does it this way to prevent getting it back. Also, concerning your comment “labwork as ordered” I find that clinicians do not initially understand that the red section on the oasis is what is used for orders on the 485.

    August 23, 2010

    • You are so correct. The thing is that most of us would never create a very long form without offering instructions on how to use it. Yet, we buy commercial forms such as Briggs or MedPass without ever offering training on them. It would be nice if the publishers of these forms would offer some sort of education to go along with them. If anyone knows of any, please post below for us all!

      August 23, 2010

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