Care plan and Care plan 

Review Workflow

Care Plan - Clinical Workflow Overview

The resident Care Plan tab allows you to create a new Care Plan when the resident is first admitted to your facility and take you through to the first Care Plan review required and edits in between reviews.

This topic helps those training Care Plans to others understand the workflows taken from new admission through to the end of the first Care Plan review.

Procedure

  1. Resident is admitted and you create a Care Plan by clicking New in the Care Plan tab of the resident chart. A popup appears that initializes the Care Plan.
  2. From the Care Plan Detail page, the Care Plan is completely blank with only buttons to add New Focus, New Custom Focus, Printable View, Back, Care Plan PN, New Alert, Jump to MDS. 
  3. Click View Triggered Items Now to begin building your active plan through triggers from MDS, assessments and progress notes. This area is not the Care Plan, but an area for items pushed from other areas of the chart to sit until added/removed.
  4. From the View Triggered Items screen, select the Focus, Goal and Intervention item(s) you wish to add and click Save. These items are visible on the Care Plan Detail page and are a part of the resident's active Care Plan.
  5. Make edits to any items that require personalization or require changes and save item(s).
  6. Add additional items as required to the Care Plan through the New Focus button (or New Custom Focus button) and create goal(s), intervention(s) using the Care Plan wizard. Personalize/edit as required.
  7. When you are done, click Back to exit.
  8. You can make changes by clicking the edit link.
  9. When the first Care Plan Review is required, click New Review in the Review History area. Select the Review Start Date and Target Completion Date and Assign Reviewers as needed. Click Save. 

  1. Click edit next in the Review History section and click edit next to your department as applicable.
  2. Click View Triggered Items Now to begin adding to your active Care Plan through triggers from MDS, assessments and progress notes. This area is not the active Care Plan, but an area for items pushed from other areas of the chart to sit until added/removed.

  1. From the View Triggered Items screen, select the Focus, Goal and Intervention item(s) to add to the Care Plan and click Save. These items are visible on the Care Plan Detail page and are a part of the resident's active Care Plan.
  2. Make edits to any Care Plan items that require personalization or require changes and save item(s).
  3. Add/resolve items as required to the Care Plan and personalize/edit as required.
  4. After completed Care Plan review, click Back to exit.

  1. Sign the Care Plan review for your department.
  2. After the Care Plan review is signed off for all departments, click Complete Review.
  3. The Care Plan review is complete and the Care Plan can now be edited normally.

 

SUMMARY

1. Initiate Care plan on Admission

2. Add, Edit, Resolve, and Cancel Care plans based on resident events and needs.

3. Review care plan periodically. Review initiated by MDS. Each Department signs off on their own careplans (MDS signs of on Therapy) and Click Complete Review at Care plan meeting. After the care plan review has been completed, all the goal target dates will be adjusted to three months from the date of completion.

4. Close care plan at time of discharge