Care Planning and Assessment

🔄 Quick Recall: In the last lesson, you created patient education materials at appropriate literacy levels. Now let’s use AI to organize the clinical thinking behind patient care — turning your assessments into actionable care plans.

Building Individualized Care Plans

The best care plans reflect YOUR assessment, not a standard template. Here’s the AI-assisted approach:

Help me develop a nursing care plan based on my assessment. De-identified patient:

Patient: [age, sex, diagnosis]
Relevant history: [pertinent medical/surgical/social history]
Current assessment findings: [your key findings from today]
Patient's own priorities/concerns: [what the patient says matters to them]
Barriers to care: [literacy, language, social support, financial, mobility]

Create a care plan with:
1. Top 3 nursing diagnoses (prioritized by clinical urgency)
2. For each diagnosis:
   - Measurable, time-bound goal (what the patient will achieve and when)
   - 3-5 specific nursing interventions (what I will do)
   - Evaluation criteria (how I'll know the goal was met)
3. Patient education needed for each diagnosis
4. Interdisciplinary referrals to consider

✅ Quick Check: Why does the prompt ask for “barriers to care” alongside the clinical assessment?

Because barriers determine whether interventions actually work. Teaching insulin self-injection is pointless if the patient has severe neuropathy in their hands. Providing written instructions fails if the patient can’t read English. Scheduling a follow-up appointment doesn’t help if the patient has no transportation. AI incorporates these real-world barriers into the care plan, suggesting alternative interventions that account for the patient’s actual situation.

Assessment Organization Templates

For structured, thorough assessments:

Create a focused assessment template for a patient with [condition/situation]:

Setting: [ICU / med-surg / outpatient / home health]
Frequency: [admission / shift change / focused reassessment]

Include:
1. Priority assessment areas for this condition (what to check first)
2. Specific parameters to monitor (vital sign thresholds, lab values to watch)
3. Red flags that require immediate intervention
4. Routine assessment elements to complete
5. Documentation prompts for each area

Format as a quick-reference checklist I can use during rounding.

Updating Care Plans

Care plans need regular updating as patient status changes:

My patient's condition has changed. Help me update the care plan:

Original plan: [summarize the current care plan]
What changed: [new assessment findings, new lab results, patient progress]
Current status: [better / worse / different problem emerged]

Update:
1. Which nursing diagnoses are resolved, ongoing, or new?
2. Revised goals based on current status
3. New or modified interventions
4. Updated evaluation criteria
5. Any new referrals or consultations needed

Evidence-Based Intervention Selection

When you need to choose between interventions:

I'm caring for a de-identified patient with [condition] who is [specific clinical scenario].

I'm considering these nursing interventions:
1. [intervention option 1]
2. [intervention option 2]
3. [intervention option 3]

Help me evaluate:
1. Which intervention has the strongest evidence base?
2. What are the benefits and risks of each?
3. Which is most appropriate given my patient's specific barriers: [list barriers]
4. Are there any interventions I haven't considered?

IMPORTANT: I will verify all recommendations against current clinical guidelines before implementing.

✅ Quick Check: Why does the prompt end with “I will verify all recommendations”?

Because AI can suggest interventions that sound evidence-based but may be outdated, inaccurate, or inappropriate for your specific patient. Clinical guidelines change. AI training data has a cutoff date. Some interventions require physician orders. The verification statement isn’t just a disclaimer — it’s a practice habit. AI suggests, you investigate, your clinical judgment decides.

Exercise: Build a Care Plan for Your Current Patient

Using a de-identified version of a current or recent patient:

1. Enter your assessment findings into the care planning prompt
2. Include the patient’s own priorities and barriers
3. Review the AI-generated care plan for clinical accuracy
4. Compare it to a standard template for that diagnosis — what does the individualized version capture that the template misses?
5. Identify one intervention you’d modify based on your clinical judgment

Key Takeaways

• AI generates individualized care plans from your specific assessment, not generic templates — accounting for the patient’s unique barriers and priorities
• Measurable goals specify behavior, standard, and timeframe: “Patient will ambulate 200 feet with walker by day 3” vs. “improve mobility”
• Including patient priorities (their words, their goals) improves care plan compliance and patient satisfaction
• Barriers to care (literacy, language, support, transportation) must inform intervention selection — otherwise plans look good on paper but fail in practice
• Care plans are living documents — use AI to update them efficiently when patient status changes
• Always verify AI-suggested interventions against current clinical guidelines before implementing

Up Next: In the next lesson, you’ll master clinical communication with AI — SBAR handoffs, team updates, and navigating difficult patient and family conversations.