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Plan of Care
OBJECTIVES
Identify the components of a patient plan of care from admission to
discharge

Understand the need for an environmental as well as a physical

assessment

Identify the 4 phases of the plan of care

Understand basic knowledge of OASIS

Identify the components of a clinical nursing note - what should every

clinical nursing note contain.

Suggest the how, what and why of concise and inclusive

documentation.

Understand the need of the clinical note to demonstrate an

assessment of the individual patient’s needs, an established and well
defined plan of care and the patient’s response to the care provided.

Demonstrate through the clinical note, the use of the nursing process
utilized to provide care, and the care provided was within the scope
of established practice guidelines.

 Describe SBAR communication

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 Describe the role of rehab nursing

Skilled Care Requirements for Homecare
THERAPEUTIC, REHABILITATIVE, & PALLIATIVE
SHORT TERM & INTERMITTENT
HOMEBOUND
SIGNED PHYSICIAN ORDERS
OBSERVATION & ASSESSMENT
TEACHING & TRAINING ACTIVITIES
SPECIFIC TREATMENTS
Plan of care ( the 485)
PATIENT DEMOGRAPHIC DATA
PRIMARY & SECONDARY DIAGNOSES
SURGICAL PROCEDURES
START OF CARE DATE
FUNCTIONAL LIMITATIONS
ASSISTIVE DEVICES
DIET, MEDICATIONS & ALLERGIES,TREATMENTS
TYPES OF SERVICES & VISIT FRQUENCY
Four Phases of the Plan of Care
Diagnosing Phase
Planning Phase
Implementing Phase
Evaluating Phase
IF NEEDED A LIST OF MEDICAL/SURGICAL SUPPLIES

GOALS WRITTEN IN SMART TERMS FOR A 60 DAY TIME FRAME

SMART=SPECIFIC.
SMART=SPECIFIC. MEASURABLE, ACCURATE, REALISTIC & TIME-
FRAMED
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Admission Assessment (OASIS)

OASIS- Outcome Assessment Information Set
Inpatient History
Prior medical regimens
Current prognosis
Living arrangements
Support systems
Review of systems ( Physical assessment)
Pain assessment
OASIS & Assessment
WOUND ASSESSMENT & ULCER STAGING
CONTINENCE LEVEL
EMOTIONAL/BEHAVIORAL STATUS
FUNCTIONAL ACTIVITIES OF DAILY LIVING
FUNCTIONAL LIMITATIONS
EQUIPMENT USE & STORAGE
REHABILITATION NEEDS
Accreditation Requirements for Assessment
SPIRITUAL ASSESSMENT
SKIN ASSESSMENT: BRADEN SCALE
HOME SAFETY
HEALTH SCREENINGS
IMMUNIZATION HISTORY
FALLS RISK ASSESSMENT
NUTRITION
TOBACCO/ETOH/DRUG/CAFFEINE USE
LEARNING NEEDS & RESPONSE TO EDUCATION

Purpose of Clinical Documentation

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Ensure better continuity of care.
Clinical notes display follow through enhancing positive patient
outcomes.
Serve as a communication tool between all disciplines, including
Physicians, Pharmacist, PT, OT, SW, ST and HHA. Simply stated your
note should be interdisciplinary with all involved team members, and
each discipline should integrate the patient’s individual identified
problems and their individualized plan of care.
Clinical notes serves as a supplement along with flow sheets and
charts to identify progress, lack of progress or trends that an
individual patient is experiencing. Clinical notes never stand alone.
Clinical notes serve as a benchmark for communicating patient
responses and interventions to treatment.
Clinical notes are communication tools that display the nursing care
that was rendered.
Clinical notes should display the nursing care provided by a reasonable
and prudent nurse within the scope of his or her established
standard of care practice guidelines.
Clinical notes should follow Policy and Procedure as defined by the
institution of which you are employed. If you are unsure how to
document an event consult with your nurse manager, nursing
supervisor, risk manager or legal representative of your institution.
History of Documentation
PIE (1984), problem, intervention and evaluation.
Narrative (commonly used as a system assessment in Critical Care
areas - ICU, CCU, TEMETRY AND ER).
Problem oriented charting - subjective, objective, assessment
planning (SOAP notes).
Focus notes (1981), data, action and response notes (common type
of documentation in ER).
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Chart by exception (CBE), documenting only problems or
abnormalities.
CC areas tend to use a combination of all types listed above - most
important point is to be specific, inclusive and yet concise. Simple is
best, do not complicate your charting.
Charting by exception (CBE)
Advantages related to CBE:
Establishes a baseline and defines “normal” assessment.
Charting time decreased.
Avoids repetition of routine care.
CBE along with flow charts helps in identifying trends.
Disadvantages related to CBE:
Lack of problem identification to support plan of care.
Lack of integrated notes with other disciplines.
Lack of narrative notes places heavy emphasis on flow sheets to
support care provided.
CBE
Documenter must identify the problem clearly.
Documenter must use flow sheets at all times.
Documenter must use teaching sheets to the fullest extent, being
inclusive of other disciplines, specific to the problem and direct in
establishing a plan of care.
Documentation should include:
Complete head to toe assessment every shift.
All patient treatments and their response to the treatment
Education of patient and their family from admission to discharge.
Any and all interdisciplinary conferencing and teaching.
Any change in the patient’s condition.
All conversations with involved physicians as it relates to the individual
patient’s care.
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Any adverse event or outcome, exclusive of the actual mention of the
completion of an event report. In an event report state the facts
only, with specific clinical findings, not your personal reasons why or
how this could have been avoided, e.g. inadequate staffing or quality
of another nurse should be discussed in private with the appropriate
authority not documented in an event report.
Documentation should NOT include:
Personal judgments of a patient or their family members.
Documentation stating that an event report was completed.
Disagreements with other members of the healthcare team.
Home care documentation acceptable words & phrases
Acute, Beginning to Respond,
Began Continuous Instructions,
Began Instructing, Assessed, Taught, Bed Confined,
Chair Confined, Specific Amount of drainage in cc, Poor Balance,
Exhausted with Exertion, Is Unable, Removed from home by family,
Per request of Physician, Transported to Physician by.
Clinical responsibilities
DISEASE PROCESS
MEDICATION
NUTRITION/HYDRATION
ACTIVITY
TREATMENTS
PSYCHOSOCIAL/MENTAL STATUS
INTERTEAM SERVICES COORDINATION
SBAR Communication – (See Handout)
What is it?
Why important to use?
How is it done?
Legal issues in Home Care
3 Legal actions which can be taken
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Criminal
Administrative Law Actions
Civil Actions
PERMISSION TO TREAT
PYSICIAN ORDERS FOR TREATMENT
PATIENT RIGHTS: STATE 800 NUMBER
INCIDENT REPORTS: FALLS, MEDICATIONS, & EQUIPMENT
ABUSE, NEGLECT, & EXPLOITATION
CORPORATE COMPLIANCE
Criminal Actions
Criminal- brought by the states against a person (defendants) accused
of crimes as defined by that State
Administrative- brought by state agencies to investigate complaints
( ex. The state board of nursing)
Civil-designed to resolve disputes between individuals
Ethical Issues
DEMENTIA PATIENT ALONE
FIRE & OTHER SAFETY ISSUES
PHYSICIAN CONFLICTS
NON-COMPLIANT PATIENT
USE AGENCY SOCIAL WORKER, PROTECTIVE SERVICES, & LEGAL
COUNSEL
Quality Assurance issues
ADMISSION DIAGNOSIS
OASIS OUTCOMES
INCIDENT REPORTS: FALL, EQUIPMENT, & MEDICATIONS
REHOSPITALIZATION RATE
UNANTICIPATED DEATHS
PATIENT SATISFACTION
Financial issues
PPS
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PRODUCTIVITY
SUPPLY USAGE
DENIAL RATES
TIMELINESS OF BILLING & PAYMENT
DECLINING REIMBURSEMENT
Rehabilitation
An interdisciplinary healthcare specialty, grew out of the wars of the
20th century.
Military hospitals established rehabilitation units that were focused on
returning injured and seriously disabled soldiers back into society.
Civilian rehabilitation units and hospitals began to emerge by the mid-
1940s.
What is Rehabilitation Nursing?
Rehabilitation nurses help individuals affected by chronic illness or
physical disability to:
adapt to their disabilities
achieve their greatest potential
work toward productive, independent lives. They take a holistic
approach to meeting patients’ medical, vocational, educational,
environmental and spiritual needs.
Rehabilitation nurses begin to work with individuals and their families
soon after the onset of a disabling injury or chronic illness.
They continue to provide support in the form of patient and family
education and empower these individuals when they go home or
return to work or school.
The rehabilitation nurse often teaches patients and their caregivers
how to access systems and resources.
Rehabilitation nursing is a philosophy of care, not a work setting or a
phase of treatment
Rehabilitation nurses base their practice on rehabilitative and
restorative principles by:
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managing complex medical issues
collaborating with other specialists
providing ongoing patient/caregiver education
setting goals for maximal independence
establishing plans of care to maintain optimal wellness
Rehabilitation nurses practice in all settings
freestanding rehabilitation facilities
hospitals (inpatient rehabilitation units)
long-term sub-acute care facilities/skilled nursing facilities
long-term acute care facilities
comprehensive outpatient rehab facilities
private practice
home healthcare agencies
clinics and day rehabilitation programs
community and government agencies
insurance companies and health maintenance organizations
schools and universities
Rehabilitation Nurses
Have excellent functional assessment skills and take a comprehensive
approach to care.
They act as multisystem integrators and team leaders, working with
physicians, therapists, and others to solve problems and promote
patients’ maximal independence.
Skilled at working with others to adapt ongoing care to the resources
available.
Act as caregivers but also as coordinators, collaborators, counselors,
and case managers.
A registered nurse with at least 2 years of practice in rehabilitation
nursing can earn distinction as a Certified Rehabilitation Registered
Nurse (CRRN®) by successfully completing an examination that
validates expertise
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