How to Complete a Nursing Plan (NPOC)?

How do I complete a Nurse Care Plan?

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An important task for nurses is to create a plan of care for the individuals on their caseload. This important record can be created in the system. Let's look at the steps to produce this nursing document.

Here's how:

  1. Begin by going into the profile section and then the Medical Info tab. 
  2. Next you will add in all Allergies using our global list and the + sign. If you need to add an allergy not found on our list you can click the Add Custom link to add this new information. Once finished make sure to save the section. 
  3. Then you will add in all the diagnoses for this individual. Again, you can use our global list or Add Custom feature. 
  4. Once you have the diagnoses entered you must give each one a type: Medical or Psychiatric.
  5. The next step is to add your nursing diagnosis or description in the Services box. You can add multiple items here by clicking the + sign each time. 
  6. You can select the date the diagnosis has been recorded and then save this section
  7. This is what this section should look like before you move on. Information entered into Other Diagnosis will not show on the Plan of Care. This section is best used for historical information.

8. Now you will move to the eChart and the Services button.

9. Here inside services, you will see the diagnoses you have entered and their related services.

10. Start by selecting the correct program (if there is more than one)Here you will see the Diagnosis information. This information is pulling from the profile.

11. Click the right facing arrow to expose your nursing diagnosis/related service information. You will see the fields to the right to be filled out: Description, Nursing Interventions and Goals. There is also an evaluation field for future use during review. Enter your information and then click the save button.

12. Repeat this process for all diagnoses-both medical and Psych. To see the psych diagnoses, use the blue button above the diagnoses list

13. To add any extra nursing diagnoses, you click the green plan button

14. Select Nursing Diagnosis Objectives and then enter this information, click the + sign and save. 

15. Once all information has been entered at the top of the screen you click on the blue Nursing Plan button.

16. Click on Add Nursing Plan and select your plan date and enter your name. The next screen pulls the plan along with all the data you entered in Services. You can select the plan date and enter your name. This is the best time to check and make sure the data shows as you want it to.  If something is not correct you will need to go back to Services to edit. You can then customize the order in which the diagnoses appear.

17. When you are ready click on Generate Plan of Care. This will then take you to the Nursing Plan of Care list.

18. Now you can view, sign and finalize your plan.

19. Once you have signed and finalized the document you have the ability to download, print or fax. Other staff have the ability to sign the document at this point.

20. Here is a look at the final document.

We hope you enjoy this newly enhanced feature. Please reach out with any questions or feedback.

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