DA Form 3888-2. Medical Record - Nursing Care Plan
The DA Form 3888-2, known as the Medical Record - Nursing Care Plan, is used to develop and document individualized care plans for patients in healthcare settings. This form is typically utilized by nurses or other healthcare professionals involved in the planning and delivery of patient care.
The form consists of sections that capture important information related to the nursing care plan. These sections include patient, nursing diagnoses, goals, interventions, and evaluation of outcomes. The form provides fields for recording the patient's name, age, gender, and other identifying details.
When filling out the DA Form 3888-2, it is crucial to develop a comprehensive and tailored care plan based on the patient's needs and condition. Patient details, such as name and date of birth, should be recorded correctly to ensure proper and avoid any confusion.
The nursing diagnoses section allows for identifying and documenting the patient's nursing care needs. This involves analyzing assessment data, identifying actual or potential problems, and formulating nursing diagnoses based on standardized nursing terminology.
The goals section provides space to establish specific, measurable, achievable, relevant, and time-bound (SMART) goals for each nursing diagnosis. Interventions are documented in the interventions section, outlining the nursing actions and strategies to address the identified nursing diagnoses and achieve the established goals.
The form also includes a section for evaluating the outcomes of the nursing interventions. This involves assessing the patient's response to the care provided, determining the effectiveness of the interventions, and making any necessary adjustments to the care plan.
An example application of the DA Form 3888-2 would be in various healthcare settings where nurses are involved in developing and implementing care plans for patients. By using this form, nurses can document the nursing diagnoses, set goals, plan interventions, and evaluate the outcomes of their care. The form serves as a tool for care coordination, communication among healthcare providers, and documentation of the nursing process.
It is important to note that specific procedures and guidelines may vary depending on the healthcare facility or organization. Therefore, individuals should consult the appropriate protocols or instructions to ensure compliance with the correct processes when using the DA Form 3888-2.