Writing Care Plan Problem Statements

The problem statement sums up assessment information into a specific functional category. No federal regulation specifies the exact wording or structure of the problem statement, but theMDS 3.0 RAI Users Manual states that problems should be written in functional or behavioral terms. 

Problem statements are traditionally based on a nursing diagnosis. The nursing diagnosis is a problem that nurses can identify and treat. Medical diagnoses can be part of the problem statement, but not the actual problem itself. The most commonly used nursing diagnoses are the ones approved by NANDA, the North American Nursing Diagnosis Association, and are grouped by functional health patterns. 

Elements often included are:

Whether the problem is actual or potential

What the problem is related to, such as medical diagnosis

Objective signs and symptoms of the problem, such as physical assessments and observations

Subjective data, such as the resident’s complaints and nonverbal messages 

The first part of the problem statement describes the resident’s actual or potential functional deficit:

Activity Intolerance 

Medical diagnoses can be added to the statement with the words “related to”:

Activity Intolerance related to COPD 

Objective and subjective data can be specified in the form of the words “as evidenced by”:

Activity Intolerance related to COPD

As evidenced by:

Shortness of breath

Resident verbalizes fatigue when walking in corridor 

Federal regulations are specific that the facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS orCare Area Assessments (CAAs). 

A sound practice for care-planning is to follow a check-list of problem identification: 

Address all problems triggered in the CAAs.

Review MDS sections and entries.

Review the resident’s entire chart.

Review the resident’s list of medical diagnoses and all medications.

Focus on the resident’s particular and individual strengths, needs, and preferences. These may become clearer during the care plan meeting, working with the care plan team.

Review the Quality Indicators and Quality Measures triggered by the MDS.

Read all quarterly assessments such as falls, restraints, etc.

The problem should be dated and initialed when entered, changed, or deleted. 

Complete Nursing Care Plans for Long Term Care - 143 Nursing Care Plans for Long Term Care in the book and on the CD