Standardized nursing care plans for acute care SCI: improved documentation.

Abstract

Adequate documentation of spinal cord injury (SCI) nursing care is necessary for evaluation of patient progress and compliance with standards of care. The objective criteria used to evaluate nursing care include the nursing data base, the care plan, and the nurses' notes. The nursing care plan reflects the needs of the SCI client and is the basis from which documentation about these needs arises. Standards for acute care SCI nursing were recently developed for the 10 designated SCI centers in Florida. To improve the documentation of these standards, neuroscience nurses at Shands Hospital developed standardized care plans that can be individualized for each SCI client. The implementation of these care plans improved documentation of the standards for acute care SCI nursing. Additional benefits included an increased awareness of the nursing diagnoses among staff nurses and improved equality of care for the SCI client.