Patient Care Plan Template

Project RED (Re-Engineered Discharge) Training Program

Provides a four-module training program to help hospitals implement Project RED.

Patient Care Plan Template

There are three steps for preparing your hospital's patient care plan template:

  • Confirm the approach.
  • Develop the solution.
  • Define policies and procedures for use.

Confirm the Approach

Options for developing the patient care plan include:

  1. The Discharge Advocate (DA) enters patient information into a fillable-PDF that is stored on the hospital server.
  2. The hospital Information Technology (IT) Department integrates the fillable-PDF with the hospital's electronic medical record (EMR) and existing discharge instruction materials or creates a template that mirrors Boston Medical Center's after hospital care plan for Project RED (Re-Engineered Discharge).
  3. The hospital purchases commercial Project RED software that is integrated with the hospital's EMR to generate the Project RED Patient Care Plan.

Your hospital should review these options and consider which approach to use in piloting Project RED. Considerations include the anticipated volume of patients during the initial pilot project, the time it will take the DA to enter patient information with a less-integrated template, IT staff time for building interfaces, and cost of commercial software and support. A table listing possible advantages and disadvantages to each option is provided below.

OptionAdvantagesDisadvantages
DA enters patient information into a fillable-PDF that is stored on the hospital server.
  • Available for use immediately
  • Eliminates handwritten care plan.
  • Requires limited IT involvement.
  • Creates possible redundancy or overlap with existing discharge forms used in hospital.
  • Requires DA to manually enter all data.
Hospital (IT) Department integrates the fillable-PDF with the hospital's EMR and existing discharge instruction materials or creates a template that mirrors Boston Medical Center's after hospital care plan for Project RED.
  • Reduces amount of data DA must enter.
  • Reduces potential duplication or overlap with existing forms.
  • Requires IT time and resource investment.
  • Causes a potential delay in launch of Project RED intervention while template is being completed.
Hospital purchases commercial Project RED software that is integrated with the hospital's EMR to generate the Project RED Patient Care Plan.
  • Exists as commercial software.
  • Reduces amount of data DA must enter.
  • Reduces potential duplication or overlap with existing forms,
  • Requires extra funds for software purchase.
  • Entails IT Department time and resource investment for integrating software with hospital's EMR.
  • Causes a possible delay in launch of Project RED intervention while integration is being completed.

Develop the Solution

Each of the three options requires some level of IT involvement and direction for the DA's use of the patient care plan. In addition, the IT staff may also be involved in operationalizing policy decisions related to saving and storing the completed patient care plan once the patient is discharged. For example, if leaders decide that the patient care plan will be a permanent part of the patient record, the IT and Medical Records departments may need to determine how to link or combine the patient care plan with the patient record.

With the first option, IT staff should be involved in deciding where and how the patient care plan template will be stored on the server so the DA can easily access it when a new patient in the targeted population is admitted.

With the second option, IT staff will need to program interfaces with other hospital systems. Interfaces may allow for pre-population of certain sections of the care plan and for the DA to access content from clinical systems to add to or create the patient care plan.

With the third option, IT staff will work with the commercial product vendor to integrate the Project RED software with the hospital's EMR.

With all options, the build should be tested to ensure the template is easily accessed, used, and stored as unique patient care plans.

Define Policies and Procedures for Use

At a minimum, policies and procedures should focus on accessing the template, completing the patient care plan, saving each patient's unique care plan, and storing the final patient care plan.

Policy statements may be limited to:

  • Where and how the unique patient care plan is stored, including whether or not it becomes a permanent part of the patient record.
  • Who is responsible for completing the patient care plan and for teaching and providing it to the patient and family.
  • Who else receives a copy of the patient care plan (i.e., primary care provider [PCP]).
  • Who sends a copy of the care plan to the PCP and how it is sent.

Procedures (or directions) should be written to address:

  • How to access the care plan template (for example, where it is on the server).
  • How to initiate a patient care plan for a newly admitted patient in the targeted population.
  • How and where to save the unique patient care plan.
  • How to access other electronic patient information.
  • How and where to permanently store the final patient care plan.
  • How to provide a copy of the care plan to others.

As noted above, the IT and Medical Records departments may need to be involved in creating these procedures.

Developing Your Patient Care Plan Template

If you plan to create your own hospital-specific patient care plan, ensure that the following components from Boston Medical Center's plan have been included:

  • Individual hard copy care plan (language specific).
  • Medication calendars in lay terms.
  • Daily morning, afternoon, and evening medications.
  • Patient questions list.
  • Scheduled follow-up appointments.
  • Pending tests and results.
  • Location of appointments.

Checklist for Patient Care Plan Deployment

______   Approach confirmed for developing patient care plan.
______   Boston Medical Center plan's components confirmed on the patient care plan.
______   IT staff identified to assist with developing solution.
______   Interfaces with other systems determined.
______   Location finalized for storing blank patient care plan template.
______   Process defined for accessing blank patient care plan template.
______   Process defined for saving unique patient care plan.
______   Decision made on plan becoming permanent part of patient record.
______   Process developed for permanently storing the completed patient care plan.
______   Patient care plan template completed.
______   DA oriented on how to access, use, save, and store patient care plan.

Return to Contents

Current as of August 2011
Internet Citation: Patient Care Plan Template: Project RED (Re-Engineered Discharge) Training Program. August 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/careplan.html