Plan of Care Preparation
Plan of care
A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient’s nursing problems.
The nursing process itself is a problem-solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories.
CORE OBJECTIVE has a team of HCPs who have the hands-on experience of patient care, treatment and accordingly they would help you prepare a plan of care for your patients.
We have an highly experienced team that works very closely with your teams and ensure that your patients get a customized plan of care based on their medical history and future needs.
Before your patients receive Medicare-covered home health care, your Home Health Agency (HHA) should assess their condition to create a plan of care. We work with the HHA, Clinics, Hospitals in preparing a plan of care for each patient that needs it once the treatment is completed.
Generally, plan of care will list:
The types of health services and items the patients need
How often they will
receive services
The predicted outcomes
of treatment
The treating doctor must sign the plan of care at the start of care or soon after it starts. The plan of care is often paired with the home health certification form that the doctor must sign to show the patient needs care. The first time the doctor certifies patient’s eligibility for home health care, the patient must have a face-to-face meeting to discuss the reason they need care.
The initial plan of care and certification will last 60 days. If the patient needs additional care, the certification and plan of care can be renewed for as many 60-day periods as necessary, as long as the doctor continues to sign them. The patient has to make sure that treating doctor agrees with the plan of care and thinks it contains all the care the patient needs. A face-to-face meeting is not required for re-certification.
Plan of Care Steps and Critical Content
Assessment (collect data from medical record, do a physical assessment of the patient, assess adl’s, look up information about your patient’s medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient’s problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)
The Core Purpose of the Written Care Plan
- A care plan flows from each patient’s unique list of diagnoses and should be organized by the individual’s specific needs.
- Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.
- Care plans help teach documentation. The care plan should specifically outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require.
- They serve as a guide for assigning staff to care for the client. There may be aspects of the patient’s care that need to be assigned to team members with specific skills.
- Care plans serve as a guide for reimbursement. Medicare and Medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.
Care Plan Formats
The exact format for a nursing care plan varies slightly from place to place. They are generally organized by four categories: nursing diagnoses or problem list; goals and outcome criteria; nursing orders; and evaluation.
As defined by the North American Nursing Diagnosis Organization-International (NANDA-I), nursing diagnoses are clinical judgments about actual or potential individual, family or community experiences or responses to health problems or life processes.
