- Completion of care plan details:
- Percent of care plans with medication list included.
- Percent of care plans with care needs included (e.g., exercise, diet, main problem, when do I call doctor).
- Percent of care plans with follow-up appointments listed.
- Percent of care plans with pre-arranged discharge resources identified (e.g., home health, durable medical equipment).
- Percent of care plans with pending tests listed.
Your organization will need to determine the structure and process for the Patient Care Plan. Will it be a hard copy form with manual documentation? Or will it be an automated printout as a component part of your electronic medical record (EMR) system?
The DA and team will have a copy of the Patient Care Plan, regardless of the format, and will be able to collect data from it that is specific to the patient.
Your organization may decide to review the final Patient Care Plans to assess the completeness. This can be accomplished by printing an extra copy at discharge and asking your quality department to audit it.