Plan of Care and Care Delivery

[Virtual Presenter] Plan of Care and Care Delivery.

[Virtual Presenter] purpose: To provide guidance to all Military healthcare facilities for standardizing and organizing the process of planning and delivery of care for all patients. To ensure integration and coordination of plan of care and delivery of care..

[Virtual Presenter] reference: Joint Commission international, 5TH Edition Hospital Standards, 2014 responsibility OF: Director of Medical Administration, All Clinical Directors, Director of Nursing, Director of Patient Affairs, Pharmacy Director, Non Clinical Support Director APPLICABLE TO: Patient population: All inpatients & outpatients, Hospital Departments: Medical Administration, Nursing Administration.

[Audio] 1. policy 1.1 All military Healthcare facilities must ensure a uniform care process that is reflected in the following: 1.1.1 Access to and appropriateness of care and treatment shall not depend on the patient's ability to pay or the source of payment. 1.1.2 Access to appropriate care and treatment by qualified providers does 1.1.3 Acuity of the patient's condition determines the resources allocated to meet the patient's needs. 1.1.4 The level of care provided to patients is the same throughout the facility. 1.1.5 Patients with the same nursing care needs receive comparable levels of nursing care throughout facility..

[Audio] 1.2 All patients admitted to any military hospital shall have their care planned collaboratively by all healthcare providers of different settings, departments and services involved in their care. 1.3 All patients seen in the outpatient clinics shall have their care planned by their healthcare providers. 1.4 The initial plan of care shall be individualized and based on the data obtained, and the needs identified, through the inpatient's initial (medical / nursing) assessment process. 1.5 The plan of care for outpatients must be individualized and based on the data obtained, and the needs identified, through outpatient assessment by the different healthcare providers involved in their care, before seeing the next patient. 1.6 The initial care plan for in-patients must be completed and documented in the patients record within 24 hours of admission..

[Audio] 1.7 Health care providers must document their plans of care in one of following designated forms: 1.7.1 Assessment/encounter forms. 1.7.2 Progress notes. 1.7.3 Specialty specific care plan forms. 1.8 For inpatients, the Registered Nurse (R-N---) is responsible for coordination of in-patient’s plans of care developed by the different healthcare providers involved in patient care using the integrated, interdisciplinary plan of care tool 1.9 Physicians orders are considered as physician plan of care, but plan of care are not considered as orders. 1.10 The plan of care is to be updated or revised, as appropriate, based on the reassessment of the patient by the healthcare providers. 1.11 The care provided /delivered for in-patients or out-patients, by any healthcare providers, to be documented in the patient's record. 1.12 Patients and (as appropriate) their guardians must be informed about the care outcomes including unanticipated outcomes of care..

[Audio] definition OF terms Plan: A detailed method, formulated beforehand, that identifies needs, lists strategies to meet those needs, and sets goals and objectives. The format of the plan may include narratives, policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these. Plan of Care: A plan that identifies the patient's care needs, lists the strategy to meet those needs, documents treatment goals and objectives, outlines the criteria for ending interventions, and documents the individual's progress in meeting specified goals and objectives. It is based on data gathered during patient assessment. The format of the plan may be guided by specific policies and procedure, protocols, practice guidelines, clinical paths, or a combination of these. The plan of care may include prevention, care, treatment and rehabilitation..