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Nursing assessment, care planning, and education are crucial components to improving patient care


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After reading this article, you will be able to:

1. State what a hospital must define in writing about an assessment

2. Describe common assessment mistakes that hospitals make

3. List ways to improve the care planning process

4. Understand ways to improve the educational assessment process

Your hospital’s nursing assessment, care planning, and education should be coordinated to tell the story of nonphysician patient care and serve as key documents for caregivers, said Patricia Pejakovich, RN, BSN, MPA, CPHQ, during the First Annual Association for Healthcare Accreditation Professionals (AHAP) Conference held May 3–4 in Las Vegas.

Nursing assessments

The most common problem that hospitals have dealing with nursing assessments is not knowing exactly what the standards say and what is required in an assessment, said Pejakovich, a consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

For example, Joint Commission standard PC.2.20, EP 1, says that a hospital must define in writing: 

  • In what settings the assessment will be done
  • The content of the assessment
  • The criteria for more in-depth assessment

    However, the standard does not require nursing assessments to take place in settings such as same-day surgery, the OR, the emergency department, or a physician office practice. “They are only requirements if the hospital defines them as such,” Pejakovich said.

    Other common errors hospitals make with this standard, according to Pejakovich, include:

  • Trying to apply an inpatient assessment to an outpatient setting
  • Not defining what information is needed to perform nursing care
  • Collecting information that will not be used in the specific care setting

    Another assessment standard, PC.2.20, EP 4, states that information gathered during an initial assessment should be “relevant to the care, treatment, and services.”

    “A functional screen or a nutritional screen is not required for all patient care settings,” Pejakovich said. “But if you collect it, be prepared to address it.” 

    Standard PC.2.20, EP 5, requires hospitals to define criteria for when nutritional plans must be developed, but this does not mean nutritional screens are required, she said. 

    PC.2.130 continues to reinforce that assessments are truly determined by the hospital. The standard says that patients are to be assessed per hospital policy, and that an RN should assess the patient’s need for nursing care in all settings, as required by law, regulation, or hospital policy, Pejakovich said.

    The same standards apply to reassessments, as shown in PC.2.150, which states that each patient is reassessed as needed, although it doesn’t state a required frequency or content. Reassessments are actually often overdone, according to Pejakovich, and they should be done only when they are meaningful, not just to complete routine paperwork.

    Care planning

    “If you’re filling out a piece of paper or a computer screen, because it is required, but you never will look at it again, why bother?” Pejakovich asked in regard to the care planning process.

    Instead of putting every patient through the same process, ask the patient’s caregiver:

  • What care is a priority for the patient today?
  • How were you informed of these patient care needs?
  • Are the patient’s needs reflected in the care plan?

    Standard PC.4.10, EP 6, deals specifically with care planning, but many hospitals make their policies more complicated than necessary. The easiest way to set up a care planning chart, according to Pejakovich, is to make a table with the following column headings:

  • Issue
  • Interventions
  • Goal
  • Resolution date

    This leaves nurses free to make changes as needed, such as placing a patient in isolation or revising a patient’s needs due to complications.

    For specific areas of care, such as obstetrics, you may define what constitutes routine care, but you should leave room for when nonroutine issues occur, she added.

    All care planning really comes back to standard PC.5.10, which requires you to follow the care plan. As long as you say what you do and do what you say, you should be fine here, Pejakovich said. 

    If you list an intervention as part of the plan, you must carry it out and document it, but if it’s something that won’t always be necessary, don’t make it part of your routine care planning.

    Education

    In this case, education refers to the education assessment performed on patients, specified in PC.6.10, EP 2. The education assessment should include:

  • Cultural and religious beliefs
  • Emotional barriers
  • Desire and motivation to learn
  • Physical or cognitive limitations
  • Barriers to communication

    But the key piece to PC.6.10 is EP 3, according to Pejakovich. It says the education should be done “as appropriate to the patient’s condition and assessed needs.” Again, this means that preprinted materials aren’t necessary, because the topics about which you educate a patient should vary depending on how you assess his or her educational needs.

    One way to keep the educational assessment prominent when it comes to educating a patient is by keeping the educational assessment form near the top of the chart and with the education form, Pejakovich suggested.

    Standard PC.6.30 supports this theory by stating that:

  • Education should be appropriate to a patient’s abilities
  • Education should be coordinated among disciplines
  • Content should be presented in an understandable way
  • Teaching methods should accommodate different learning styles
  • Comprehension should be evaluated

    Hospitals most often fail with this standard, according to Pejakovich, because they don’t alter their teaching methods to take into account language barriers or patients who say they learn better by video rather than from handouts, the education is considered complete even when the patient acts/is confused, or all education is delivered as part of discharge instructions and not as needed on separate occasions.