Skilled Management and Evaluation of a Care Plan ….ppt

* Make a LIST!!!!! Keep orders to a minimum-based on goals established Orders must be related to diagnosis codes established Include Process Measures (OASIS Synopsis Items ) when applicable. Orders should be your ROADMAP to positive patient outcomes KEEP IT SIMPLE - Establishing Goals (cont.) List specific orders: Observation and Assessment (remember the 3 week time frame) Teaching: WHO will be taught? WHAT will be taught? Direct Care: Wound care - include specific treatments, frequency of treatment, identify who will PERFORM treatments, frequency of nurse evaluation of wound (if caregiver/patient will do the routine wound care), specific supplies to be used, etc. Infusion, lab draws, blood glucose monitoring, patient weights Notifying Physician of Parameters ? 2014, A.D. Maxim Consulting, LLC * KEEP IT SIMPLE - Establishing Goals (cont.) DISCHARGE? Are they ahead of plan? May need to discharge early, would need to discuss and provide discharge notices and notify the physician RECERTIFICATION? Are they making slow progress? Document barriers to progress – education level or low literacy, poor coping skills, multiple caregivers involved, changes in medication or treatment * EVALUATION – Is the Plan Working? Evaluation - Is the Plan Working?DISCHARGE ? 2014, A.D. Maxim Consulting, LLC * Document discharge planning EVERY VISIT with patient/CG in revisit notes Develop plans for care after home health ends – follow-up lab draws, physician appointments Summarize episode and notify physician of anticipated discharge – see sample discharge summary Document all teaching at discharge visit including safety recommendations, physician follow up, ER plan ? 2014, A.D. Maxim Consulting, LLC * Deciding to Discharge Sample Discharge Summary List all original goals Document interventions performed Document status (met or unmet) Summarize entire episode, all disciplines involved Send to physician – office can mail or fax ? 2014, A.D. Maxim Consulting, LLC * D