A Study of the Effect of Standard Nursing Care Plans on Nurses' Documentation on Individualized Care Plans and Patient Medical Records

摘要

This report details the results of an experimental study to determine the effect of standard nursing plans on nurses' documentation on individualized care plans and patient medical records on one 60 bed medical ward. Nursing care plans were audited before and after standard care plans were developed and introduced. Findings of the study indicated that nurses utilized standard nursing care plans when available and that documentation was found to be more complete in several areas in both the individual care plan and the patient medical record when the standard plans were used. Additional audits, care plans for other common diseases, and further study on nursing care plans were recommended. A bibliography, a sample audit form, and a course outline for teaching nurses to use nursing care plans are included.