Transcript CARE PLANNING

CARE PLANNING
BY: Khaleelah Wagner, RHIA
Health Information Management
Consultant
Date and Location:
OBJECTIVES
• Participants will identify:
– The time requirements for the CP initiation,
updating and maintenance
– The change of condition and CP content
– The interdisciplinary approach
– The Person Centered Care Plan – includes
those specific interest/request of the individual
and how the team will assist the personal
needs on resident request.
METHODOLOGY
• QA/I review of the CP and content
• Review of the ppt.
• Review of he audit in the process of CP
review,
• Evaluation of actual at randsom record.
• (treatment, therapies, weight loss,
chemical restraint)
CARE PLAN TITLE 22
• 72311 – Development of an individual,
written careplan which indicates the care
to be given the objectives to be
accomplished and the professional
discipline responsible for each element of
care,
• Objectives shall be measurable.
UPDATING CARE PLAN
• Reviewing, evaluating and updating of the
patient care plan as necessary by the
nursing staff and other professional
personnel involved in the dare of the
resident at least quarterly and more often
if there is a change in the resident’s
conditiuon.
Implementing the Resident CP
• Implementing each resident’s plan of care
according to the methods indicated in the
approaches.
• Resident’s care is carried out per the plan
and documentation supports the carrying
out of the CP.
OBRA
• CP reflects the resident; initiated on
admission, reflects the needs of the
resident
• CP developed within 21 days after
admission base on the MDS/RAPS.
CP
• Sets priorities for
care/treatment/therapies/services
• Delegates responsibility
• Provides an avenue for consistency and
continuity of care/treatment/therapies
CP COMPONENTS
• Date problem initiated – indicates due to
where applicable.
• Problem # - a method of tracking
• Problem statement – need statement
• Goals, specific measurable outcome and
time limit.
• Approaches
CP COMPONENTS-2
• Responsible discipline(s)
• Date problem resolved
Basic Mechanics
• Entries black/dark blue ink or
computerized
• Entries legible if handwritten
• Document the problem and the original
date of origin. Keep same # of the problem
re-assessed.
• Use a numbering system to utilize in
Weekly progress notes.
Basic Mechanics
• CP reflects current assessment of the
resident
• Approaches indicate the actual care,
treatment, services, therapist provided
• Interdisciplinary
CONTENT OF CP
• COnditons that relate to the diagnoses
that have been identified
• Conditions requiring treaments incuded on
CP
• Problems identified from MDS/RAPS
• New conditions
• Conditions as they relate to the
medications/ therapies given
CONTENT OF THE CP
• Problems identified from the MDS/RAPS
• Resident assessment of body check,
physical assessment, H & P,
medications/treatments ordered
• Conditions identified based on
assessment
• Conditions requiring therapies
• I &O, foley, etc.
CONTENT OF CP
• Abnormal weights, v/s
• ADL conditions/requring assistance
EVALUATE RESIDENT’S
RESPONSE
• Evaluate the resident’s response to
established goals on a weekly basis and
update the CP.
CARRYING OUT THE PLAN
• Ensure resident receives the help to
maintain or regain their optimal levels of
mental and physical health, function and
autonomy.
TIMELINESS OF CP
• Initiated on admission
• Updated as needed based on the
condition of the resident.
• Relates to the RAPS – updated when
MDS reflects re-assessment
Review of CP in REcords
• Review of the CP, identify the type of
conditions that are included and evaluate
the compliance,