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HEALTH SERVICES POLICY & PROCEDURE MANUAL North Carolina Department Of Correction Division Of Prisons SECTION: Planning Patient Care POLICY # PL 2 PAGE 1 of 2 SUBJECT: Initial Nursing Care Plan for

How to fill out initial nursing care plan

How to fill out an initial nursing care plan:

1. Start by gathering relevant patient information such as their medical history, current health condition, and any specific medical needs or concerns.
2. Assess the patient's physical, emotional, and psychological needs in order to determine appropriate nursing interventions.
3. Collaborate with other healthcare professionals, such as doctors, therapists, and social workers, to gather input and insights into the patient's care plan.
4. Identify the patient's goals and objectives for their care, ensuring that they are realistic and achievable within the given timeframe.
5. Determine the nursing interventions and actions that need to be implemented in order to meet the patient's goals. This may include administering medication, providing wound care, or assisting with activities of daily living.
6. Document the care plan in a clear and concise manner, including the goals, interventions, and expected outcomes. This documentation should be easily accessible to all members of the healthcare team.
7. Regularly evaluate the effectiveness of the care plan and make any necessary adjustments based on the patient's progress or changing needs.

Who needs an initial nursing care plan:

1. Patients who are admitted to a healthcare facility, such as a hospital, nursing home, or rehabilitation center, may require an initial nursing care plan.
2. Individuals who have complex medical conditions or multiple healthcare needs often benefit from having a comprehensive care plan in place.
3. Patients who are transitioning from one level of care to another, such as from hospital to home or from one healthcare facility to another, may require an initial care plan to ensure a smooth transition and continuity of care.
4. Individuals who require ongoing monitoring and management of chronic conditions, such as diabetes or heart disease, may require an initial nursing care plan to outline the necessary interventions and support.
5. Patients who are undergoing a surgical procedure or treatment plan that requires close nursing supervision may require an initial care plan to address their specific healthcare needs.

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What is initial nursing care plan?

Initial nursing care plan is a document that outlines the specific care needs of a patient upon admission to a healthcare facility.

Who is required to file initial nursing care plan?

The nursing staff or healthcare professionals responsible for the patient's care are required to file the initial nursing care plan.

How to fill out initial nursing care plan?

To fill out the initial nursing care plan, healthcare professionals must assess the patient's condition, identify their care needs, and develop a plan for meeting those needs.

What is the purpose of initial nursing care plan?

The purpose of the initial nursing care plan is to ensure that the patient receives appropriate and individualized care tailored to their specific needs.

What information must be reported on initial nursing care plan?

The initial nursing care plan must include the patient's medical history, current condition, care needs, treatment plan, and goals for care.