Care plan software is a comprehensive care management system that long term care facilities use to create personalized care plans for residents during their stay. Many long term care facilities have now adopted nursing home software systems because they have proven to increase efficiency and accuracy in SNFs when compared with paper documentation.
Before residents are admitted into a long term care facility, the admissions staff—usually a nurse—will need to gather a vast amount of resident data. Prior to the adoption of an efficient care plan software, admissions staff typically finds itself overwhelmed with paper documentation. This is because of the many problems of paper documents, such as:
- Information inaccuracy
- Information incompleteness
Such inefficiencies of paper documentation are likely to result in medical errors, poor resident outcomes, or even death. Meanwhile, by implementing an advanced data management system via the care plan software, nursing homes and other long term care facilities can better organize their data, thus enabling nurses to create more accurate care plans. Additionally, modern long term care software systems also come with a range of automated tools that support clinical and financial teams. Clinical and financial modules require accurate resident information to ensure proper care is administered and financial reimbursements are maximized at the facility.
Modern facilities that use data management tools during admissions find that automation tools in the software make it easier for nurses to process, store and access resident information. Once the resident data is in the long term care EHR, it is then used to create a resident’s care plan. The care plan details each resident’s illnesses and preferences.
Everything from a resident’s medical history to their meal and language preferences is recorded so caregivers can provide optimized and customized care to a nursing home resident. Furthermore, the more detailed the resident care plan is, the better the level of care. This is because caregivers understand the resident’s medical history and current condition, enabling them to adjust and implement person-centered care.
How to Create a Care Plan Using Nursing Care Plan Software
As mentioned earlier, before a resident is admitted into a long term care facility, they must first go through a series of processes so the facility can create a custom care plan using the nursing care plan software. These steps allow the facility’s admissions staff to assess the resident’s health problems and determine what support and care are needed during their stay in the facility.
It is essential for long term care facilities to accurately assess a resident’s needs to determine the appropriate level of care. The primary aim of an effective care plan is for the resident to regain as much independence as possible, both within and beyond the facility. An effective care plan software should organize data and aid the admissions process, saving nurses hundreds of hours every year.
When creating a resident care plan, admissions staff should follow these standardized five steps:
- Assessment – Upon admission, the admissions staff must collect subjective (verbal statements) and objective data (height, weight, medical history) about the resident. This data is usually collected from either the resident or their family. Once the information is collected, it is inputted into the care plan software, creating a set of digital records used during the assessment process and throughout the resident’s care.
- Diagnosis – Once the data is collected and saved in the long term care software, the admissions staff then perform a nursing diagnosis and a clinical assessment of the health conditions and life preferences. The diagnosis will determine what actionable steps a facility should take to achieve specific positive health outcomes for the resident.
- Outcomes and Planning – After the official diagnosis, the admissions staff will continue with the next step, the planning phase. This will entail following Evidence-Based Practice (EBP) guidelines that summarize a resident’s medical condition based on the evidence and specific problems. Here, staff will consider the resident’s overall condition and set achievable health outcomes during their stay.
- Implementation – Once a resident’s health outcomes have been set, the facility will work towards implementing steps to achieve the set goals. The resident’s care plan will list several interventions and physician orders for nurses to follow during the implementation phase. Furthermore, the interventions will be categorized into seven domains: behavioral, physiological; basic, physiological; complex; safety; health system; family; and community. These domains are continually updated during an episode of care with detailed feedback and review processes to ensure all vital information is recorded.
- Evaluation – In the final step of creating a comprehensive care plan, a physician or registered nurse will usually evaluate whether the resident’s treatment has met the desired outcomes. Should a resident’s condition worsen or improve, their personalized care plan will be adjusted according to the real-time needs of the resident.
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Key Features of Nursing Home Care Plan Software
For long term care facilities that have not yet adopted a long term care software system but are considering it, there are certain precautions they must take before signing a contract.
Before choosing from among nursing home care plan software vendors, facilities need to do their research and find the care plan software that makes the most sense for them. Digital care planning software comes with many features and options. Hence, a facility must first determine its needs and requirements, what departments will use the software, and what goals they hope to accomplish by investing in a long-term care EHR. Only then can a facility make an informed decision about investing in the right long term care software system.
The most effective long term care software systems will have a built-in care plan system that efficiently creates resident care plans. Some key features of a care plan system include:
- Suggested Problems – During the admissions process, when nurses initiate a new care plan for a resident, they need to add goals and interventions to build the resident’s care plan. Advanced nursing home care plan software systems will have a library of pre-saved MDS 3.0 listed problems and responses. This allows nurses to select suggested problems, improving efficiency and workflow, as they do not need to sift through the entire list of problems and interventions.
- Summary Panel – One of the most time-consuming issues with building a care plan is maneuvering between current and resolved problems. Efficient care plan software systems have enhanced user tools that allow nurses and physicians to select or deselect multiple items from multiple care plan libraries, while also allowing them to view the complete care plan on one page.
- Care Plan Progress Notes – While it’s essential to determine the goals of a care plan, tracking a resident’s progress and improvement is equally important. State-of-the-art long term care software will have numerous capabilities, such as the ability to retrieve reference problems, copy and paste notes, and edit text from different notes, which all help with care plan progress notes.
- Vitals for the EMR – A complete care plan software will display information on resident parameters, such as blood glucose levels, temperature, pulse, weight, blood pressure, respiration, and level of consciousness.
- Dashboard for Performance Indicators – Having a built-in dashboard showing performance indicators allows staff to find relevant information quickly and easily, thus, improving workflow efficiency.
- Reporting Capabilities – There are specific on-demand reports that nurses will need to see before creating a care plan, such as:
- Nursing Kardex: A tool that displays how much support a resident requires with Activities of Daily Living (ADLs).
- Care Plan: A complete document stating all the problems, goals, and interventions.
- Documentation Records: These are monthly schedules for each discipline as documented in the care plan interventions.
Transform Care Using Care Plan Software
Times are changing. There is an increase in life expectancy, an ever-growing aging population, and a shortage of nursing staff in long term care. Modern technology, such as care plan software, is an essential tool that facilities need to adapt, maintain and improve their quality of care.
While facilities may be hesitant about investing in a care plan software system, it is worth repeating that the technical capabilities of long term care EHR can positively transform resident care. Studies show that advanced technical tools ensure the continuity, safety, and quality of care, especially during handover shifts.
The automotive processes provided by nursing home software make resident care more manageable and efficient, especially when the staff has a high patient-to-nurse ratio. In addition, the standardized methods reduce human errors, which are more likely to occur during busy shifts or when nurses are overloaded with residents.
Lastly, communication between facility staff is also improved because resident records are accurately documented. In short, a nursing home team can rest easy knowing that resident data and care plans are accurate for providing quality care.