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 

Care Plans and Preventing Avoidable Declines

Surveyors will investigate if the resident declined or failed to improve relative to expectations, and determine if this was avoidable or unavoidable.
The Care Plan is a record that describes the resident’s functional abilities at different times of the past year. Make sure the documentation is comprehensive and genuinely reflects the resident’s abilities. If the goals are realistic and regularly measured, it will help to identify declines.
Surveyors will focus on the Late-loss ADLs, those considered to be the last to decline or deteriorate: Bed Mobility, Transfer, Eating, and Toilet Use. They will use the Quality Indicators and the Quality Measures, and evaluate occurrences and preventative measures.
The Admission Assessment and Care Plan should accurately document the resident’s mobility, range of motion, transfer ability, and balance. Evaluations from Physical Therapy, Occupational Therapy, and Restorative Nursing will give in-depth information about the resident’s level of functioning.

Debra Collins, RN, RAC-CT

As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term careand home health care federal regulatory changes.

She has written and published manuals for long term care and home health care documentation on nursing care plans, restorative nursing care plans,social service care plans, activities care plans, home health nursing care plans, home health nursing inservices, MDS 3.o forms for the MDS Coordinator, resources for theDirector of Nursing in long term care, nursing policy for long term care, long term care inservices, infection control for long term care, and Medicare/Medicaid documentation. The books are used by over one third of long term care facilities in the United States.

Debra has over 25 years experience in long term care and home health care. She worked as an MDS Consultant for many years, and is certified as a Resident Assessment Coordinator by AANAC, the American Association of Nurse Assessment Coordinators.

She is a member of the Bloomington Indiana Chamber of Commerce, National Nurses in Business Association, National Association for Female Executives, American Business Women’s Association, andLadies Who Launch.

Amazon Author Page Debra Collins, RN, RAC-CT

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