Care Plan

The Care Plan tab is a comprehensive list of the patient's nursing problem history. From this page, you can view, add, and/or edit the patient's care plan and nursing problem list. There are two sections on the Care Plan tab: Suggested and Care Plans. You can expand/collapse either of these sections using the black arrow button located on the tab identifying the section. (Note: The use of the Care Plan database requires licensing and setup. Contact your Account Manager for details.)

• The Suggested section displays care plans that have been triggered based on abnormal assessments.
• The Care Plan section displays activated/selected care plans for the patient. Use the Filter field to filter the list to show All, Inactive, or Active problems. To save your filter settings, go to Actions > Save Filter Settings. This saves the current settings as a default for future visits to the page. Note: This feature is controlled in User Administration by the Hospital - Patient Chart - Save Filter Settings security item.

For each nursing diagnosis listed, the created date, outcomes and interventions are displayed, as well as options to view and/or edit:

Suggested problems

The suggested section lists problems that are suggested for the plan of care based on the documentation completed on the Assessment. You can add the item to the plan of care or remove the item from the suggested list.

• Click the Add button, , to launch the  Plan of Care - Add view to add the problem to the plan of care. See To add a problem for details on using this view.
• Click the Remove button, , to remove the suggested item from the list.  

Linking care plans to abnormal assessments is done in Clinical Documentation > Patient Chart > Flowhseets > Flowsheet Assessments. From the Modify Flowsheet Assessments window > Item Values tab, click the Care Plan button that appears in the column header for Discrete and Multiselect Items to select the linked care plan.

To add a problem

1. In the Problem field, begin typing the letters for the nursing problem you are looking for. Matches to the typed text are displayed as you type.

2. Click on the desired nursing problem to display it in the Problem field. Then, click the (Add) button. The Plan of Care - Add page is displayed with detailed selection boxes for the Nursing Diagnosis and it's components.

3. In each box: Characteristics (if applicable), Related to, Outcomes, and Interventions, select the desired items to include in the plan. To select one item in the box, click to highlight it. To select additional items, press <Ctrl> + click to highlight all of the desired items in the box. Repeat for each box. If you do not find the appropriate item for the plan of care, you can free text it directly in the box. (Note: You must select at least one item in the Outcomes and Interventions boxes.) Note: Interventions are displayed in the Work Center as tasks/interventions.

4. Move the selected items to the diagnosis text box by clicking the triple right arrow button, . If you wish to remove items from the text box, highlight the desired item in the text box and then reverse the operation by using the triple left arrow button, . Or, you can move all the items in the Characteristics, Related to, Outcomes, and Interventions boxes to the text box by using the Move All button.

5. Click Save.

To edit a problem

To edit the problem, click the button located next to the item you wish to edit. The Plan of Care - Edit page is displayed. The Problem, Characteristics and Related to information is displayed in the text box on the right side of the page. From this page, you can perform the following actions:

• To remove the entire problem, click Mark Erroneous to remove it from the Care Plan. Once selected, the Plan of Care - Reason for Mark Erroneous box is displayed. Select the appropriate reason from the Reason list. Then, click Save.

• The current selections for Characteristics, Related To, Outcomes, and Interventions are displayed. To remove an item, highlight it in the box on the right and click the triple left arrow button, .    

• To move additional items to the text box, highlight the item(s) from any of the selection boxes: Characteristics, Related To, Outcomes, and Interventions. Then, click the triple right arrow button, , to move them to the text box.

Once items have been changed, click Update to save the changes. The Plan of Care - Reason for Edit box is displayed. Select the appropriate reason for editing the Plan of Care in the Reason list. Then, click Save.

Reasons for this field are maintained in the Reason Type: Plan of care Edit/Resolved in the Reason Master files located in Clinical Documentation > Master Files > Order Management. The available reasons are Issue Resolved, Change in care plan, Patient Refusal, Entered in Error, and Other.

To review the care plan

The Review plan of care function documents that a caregiver has reviewed the care plan for the current day and/or shift.

1. To access this function, click the Show Details button () located next to the problem you wish to review. The Details for the problem are displayed, as well as the Review and Resolve buttons.
2. Click Review. The Plan of Care - Review box is displayed.
3. The Reviewed On date and time default to the current. Modify, if necessary, using the calendar and clock buttons.
4. Enter additional information in the Notes box, if applicable.
5. Click Save. The review information (user, date, and action) is displayed in the Action Log section of the Details.

To resolve the care plan

The Resolve plan of care function resolves the problem when it is no longer active or appropriate for the patient.  

1. To access this function, click the Show Details button () located next to the problem you wish to review. The Details for the problem are displayed, as well as the Review and Resolve buttons.
2. Click Resolve. The Plan of Care - Resolve box is displayed.
3. The Resolved On date and time default to the current. Modify, if necessary, using the calendar and clock buttons.
4. In the Reason field, select the reason that the plan of care is being resolved.  

Reasons for this field are maintained in the Reason Type: Plan of Care Edit/Resolved in the Reason Master Files located in Clinical Documentation > Master Files > Order Management. The available reasons are Issue Resolved, Change in Care Plan, Patient Refusal, Entered in Error, and Other.

5. Click Save. The plan of care becomes inactive and be viewed by selecting All or Inactive in the Filter field. When displayed, the resolve information is displayed in the Care Plan Details.

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