1

Care Plan Redesign-Lesson 1 Nursing

Care Plans The Key to Patient Care Coordination

2

Learning Format

bull This lesson is presented in a Power Point format without audio

bull A Knowledge Check (quiz) will be presented after you have completed all four lessons

3

Objectives

bull Understand the professional and regulatory responsibilities of the health care team in planning individualized care

bull Discuss the objectives for care plan redesign

bull Articulate key features of SJH care plan policy

bull Articulate standard care plan definitions

4

Drivers for Change

bull Current state of care plan process ndash Cumbersome

ndash Not user friendly

ndash Redundant

ndash Time consuming

ndash Allows for variance in documentation

ndash Does not flow well with the nursesrsquo daily work

bull Nurses tend to regard care plans as lsquojust a requirementrsquo

bull Regulatory survey findings in many ministries have indicated weaknesses in our care plan process which warranted us to identify changes needed to improve care planning documentation across the health system

5

Goals of Redesign

bull Make it easier for clinicians to document care plan

bull Care plan documentation that is part of the clinicianrsquos workflow

bull To meet all professional and regulatory requirements of documentation

bull To make the care plan easier to view which will enhance communication between care givers

bull Create a standardized policy for all ministries

6

Important Definitions

bull Plan of Care over arching long term plan that includes all levels of care and all team members (including patient)

bull Care plan disease-specific set of related problems or health concerns with interventions completed by a specific discipline

bull Problem a stand-alone plan for a single patient issue (nausea and vomiting for example)

bull Goal the defined patient outcome to be achieved during hospital stay by discharge or by the end of a phase of care

bull Interventions actions taken to maximize the prospects of achieving the goals

bull Outcome evaluation status at one or more points during care response to care

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

2

Learning Format

bull This lesson is presented in a Power Point format without audio

bull A Knowledge Check (quiz) will be presented after you have completed all four lessons

3

Objectives

bull Understand the professional and regulatory responsibilities of the health care team in planning individualized care

bull Discuss the objectives for care plan redesign

bull Articulate key features of SJH care plan policy

bull Articulate standard care plan definitions

4

Drivers for Change

bull Current state of care plan process ndash Cumbersome

ndash Not user friendly

ndash Redundant

ndash Time consuming

ndash Allows for variance in documentation

ndash Does not flow well with the nursesrsquo daily work

bull Nurses tend to regard care plans as lsquojust a requirementrsquo

bull Regulatory survey findings in many ministries have indicated weaknesses in our care plan process which warranted us to identify changes needed to improve care planning documentation across the health system

5

Goals of Redesign

bull Make it easier for clinicians to document care plan

bull Care plan documentation that is part of the clinicianrsquos workflow

bull To meet all professional and regulatory requirements of documentation

bull To make the care plan easier to view which will enhance communication between care givers

bull Create a standardized policy for all ministries

6

Important Definitions

bull Plan of Care over arching long term plan that includes all levels of care and all team members (including patient)

bull Care plan disease-specific set of related problems or health concerns with interventions completed by a specific discipline

bull Problem a stand-alone plan for a single patient issue (nausea and vomiting for example)

bull Goal the defined patient outcome to be achieved during hospital stay by discharge or by the end of a phase of care

bull Interventions actions taken to maximize the prospects of achieving the goals

bull Outcome evaluation status at one or more points during care response to care

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

3

Objectives

bull Understand the professional and regulatory responsibilities of the health care team in planning individualized care

bull Discuss the objectives for care plan redesign

bull Articulate key features of SJH care plan policy

bull Articulate standard care plan definitions

4

Drivers for Change

bull Current state of care plan process ndash Cumbersome

ndash Not user friendly

ndash Redundant

ndash Time consuming

ndash Allows for variance in documentation

ndash Does not flow well with the nursesrsquo daily work

bull Nurses tend to regard care plans as lsquojust a requirementrsquo

bull Regulatory survey findings in many ministries have indicated weaknesses in our care plan process which warranted us to identify changes needed to improve care planning documentation across the health system

5

Goals of Redesign

bull Make it easier for clinicians to document care plan

bull Care plan documentation that is part of the clinicianrsquos workflow

bull To meet all professional and regulatory requirements of documentation

bull To make the care plan easier to view which will enhance communication between care givers

bull Create a standardized policy for all ministries

6

Important Definitions

bull Plan of Care over arching long term plan that includes all levels of care and all team members (including patient)

bull Care plan disease-specific set of related problems or health concerns with interventions completed by a specific discipline

bull Problem a stand-alone plan for a single patient issue (nausea and vomiting for example)

bull Goal the defined patient outcome to be achieved during hospital stay by discharge or by the end of a phase of care

bull Interventions actions taken to maximize the prospects of achieving the goals

bull Outcome evaluation status at one or more points during care response to care

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

4

Drivers for Change

bull Current state of care plan process ndash Cumbersome

ndash Not user friendly

ndash Redundant

ndash Time consuming

ndash Allows for variance in documentation

ndash Does not flow well with the nursesrsquo daily work

bull Nurses tend to regard care plans as lsquojust a requirementrsquo

bull Regulatory survey findings in many ministries have indicated weaknesses in our care plan process which warranted us to identify changes needed to improve care planning documentation across the health system

5

Goals of Redesign

bull Make it easier for clinicians to document care plan

bull Care plan documentation that is part of the clinicianrsquos workflow

bull To meet all professional and regulatory requirements of documentation

bull To make the care plan easier to view which will enhance communication between care givers

bull Create a standardized policy for all ministries

6

Important Definitions

bull Plan of Care over arching long term plan that includes all levels of care and all team members (including patient)

bull Care plan disease-specific set of related problems or health concerns with interventions completed by a specific discipline

bull Problem a stand-alone plan for a single patient issue (nausea and vomiting for example)

bull Goal the defined patient outcome to be achieved during hospital stay by discharge or by the end of a phase of care

bull Interventions actions taken to maximize the prospects of achieving the goals

bull Outcome evaluation status at one or more points during care response to care

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

5

Goals of Redesign

bull Make it easier for clinicians to document care plan

bull Care plan documentation that is part of the clinicianrsquos workflow

bull To meet all professional and regulatory requirements of documentation

bull To make the care plan easier to view which will enhance communication between care givers

bull Create a standardized policy for all ministries

6

Important Definitions

bull Plan of Care over arching long term plan that includes all levels of care and all team members (including patient)

bull Care plan disease-specific set of related problems or health concerns with interventions completed by a specific discipline

bull Problem a stand-alone plan for a single patient issue (nausea and vomiting for example)

bull Goal the defined patient outcome to be achieved during hospital stay by discharge or by the end of a phase of care

bull Interventions actions taken to maximize the prospects of achieving the goals

bull Outcome evaluation status at one or more points during care response to care

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

6

Important Definitions

bull Plan of Care over arching long term plan that includes all levels of care and all team members (including patient)

bull Care plan disease-specific set of related problems or health concerns with interventions completed by a specific discipline

bull Problem a stand-alone plan for a single patient issue (nausea and vomiting for example)

bull Goal the defined patient outcome to be achieved during hospital stay by discharge or by the end of a phase of care

bull Interventions actions taken to maximize the prospects of achieving the goals

bull Outcome evaluation status at one or more points during care response to care

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

7

Why Are Care Plans Needed

bull Underuse of care plans may lead to

ndash Near-misses errors and compromised care (Keenan

et al 2008)

bull The plan of care offers clinicians the ability to communicate the needs of the patient and assess outcomes of care (Estrada amp Dunn 2012)

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

8

Nurses have an Essential Role

bull The Future of Nursing report states that care coordination is one of the long-standing contributions of nurses

bull Care coordination is considered an essential competency of nurses in every level of care

bull Care coordination is critical to patient safety

bull Many experts feel that care coordination has become the

foundation of health care reform (Bahle et al 2015)

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

9

Nursing Process

bull The nursing profession has a problem-solving process that ldquocombines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific methodrdquo (Shore 1988)

bull The original concept of the nursing process was introduced in the 1950s as a three-step process of assessment planning and evaluation based on the scientific method of observing measuring gathering

data and analyzing the findings

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

10

Nursing Process

bull Over time this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the nurse practice acts of most states

bull The nursing process has expanded to five steps 1 Assessment (systematic collection of data relating to clients and their

problems and needs)

2 Diagnosis (analysis and interpretation of data)

3 Planning (prioritizing needs identifying goals and choosing solutions)

4 Implementation (putting the plan into action) and

5 Evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

11

Although some nurses view the nursing process as separate progressive steps the elements are actually interrelated Taken together they form a continuous circle of thought and action throughout the clientrsquos contact with the healthcare system The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

12

Care Planningmdashthe Professional Obligation of Registered Nurses

bull Care planning is specifically relegated to nurses in the Nurse Practice Acts in California and Texas

bull Accrediting organizations place high emphasis on the care plan (TJC 2015)

bull ANA states that the act of developing coordinating and implementing the plan of care is an essential element of RN professionalism autonomy and scope of practices

(Keller 2015)

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

13

Interdisciplinary Care Planning

bull All healthcare disciplines are interrelated and therefore the actions for each discipline have implications for the others

bull This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family

bull The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan essential in providing holistic care for the patient

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

14

Standard Process allows for Standard Policy

bull Defines purpose and definition of ldquoplan of carerdquo (POC)

bull Outlines the elements in the POC

bull Reflects the process flow of care plan initiation and documentation

bull To be adopted by each ministry by the end of April 2016

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

15

on specific elements

bull The new care plan has many new changes Three areas that will be explained in more detail on the following slides

ndashPatient desired outcome

ndashGoal (met or ongoing)

ndashPatientrsquos response to care

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

16

Patient Desired Outcome (s)

bull Presented as a ldquofree-textrdquo box

bull Documented as the patientrsquos statement of his her desired outcomes

bull Could be a short term shift goal or a long term discharge goal

bull Examples

ndash Pass gas

ndash Walk to the bathroom without help

ndash Have better pain control

ndash Sleep better

ndash Just go home

Excuse

me

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

17

Goal

bull Previously referred to as ldquoprogress towards goalrdquo ndash Met

bull The patient achieved the stated goal during the care providers time with the patient (shift)

bull The problem can still be the focus of care during for subsequent care providers even if the goal was met

ndash Ongoing

bull The patient did not achieve the stated goal during the care providers time with the patient (shift)

bull Best practice is to review Care Plan documentation BEFORE caring for the patient by using the Iatrics Care Plan Visual Flowsheet

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

18

bull A ldquofree-textrdquo box at the bottom of the care plan assessment

bull To be stated as a summary description of the patientrsquos response to care Examples ndash Able to ambulate without oxygen for further distances than

yesterday Family involved in care

ndash Patient understands plan of care and tolerated walking short distances with little to no shortness of breath In good spirits

ndash Hemodynamically stable but required frequent adjustments to vasopressors

ndash Responsive to lighter touch with increased heart rate with family in room

ndash Patient stating that food takes good and shows increased interest in food

Overall Patient Response to Care

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

19

Summary of SJH Care Plan Redesign

bull Increases ease of documentation

bull Healthcare providers can track care rendered

bull Pulls together patient care needs and issues

bull Provides proof care was given plan and outcomes were addressedmet

bull Formatted to standardize multiple disciplinesrsquo access for patient care and outcomes

bull Regulatory requirements will be met

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

20

Conclusion

ldquoAs health care professionals we have the skill and knowledge however we must never forget that the patient has to be at the center of each care team and help us to design a plan of care that will yield meaningful outcomesrdquo

~Wendy Bunting MS CCC-SLP

Director of Therapy Services

Riverside Rehabilitation Institute

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

21

References

bull Bahle J Majercik C Ludwick R Bukosky H amp Frase D (2015) At risk care plans A way to reduce readmissions and adverse events Journal of Nursing Care Quality 30(3) pp 200-204 doi 101097NCQ000000000000106

bull Dykes PC Samal L Donahue M Greenberg JO Hurley AC Hasan O OrsquoMalley TA Venkatesh AK Volk LA amp Bates DW (2014) A patient-centered longitudinal care plan Vision versus reality Journal of American Medical Informatics Association 21 pp 1082-1090 doi 101136amiajnl-2013-002454

bull Keller M (2015) Nursing care plans are essential part of scope of practice Minnesota Nursing Accent Summer pp 12 Nursing Process Theory (2016)

bull Retrieved from Nursingprocessorg httpwwwnursingprocessorgNursing-Process-Theoryhtml

bull Jansson I Bahtsevani C Pilhammar-Andersson E amp Forsberg A (2010 September 4) Factors and Conditions that Influence the Implementation of Standardized Nursing Care Plans (C C-C License Ed) The Open Nursing Journal 4 25-34

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission

22

References

bull Keenan G M Yaket E Tschannen D amp Mandeville M (2008) In Chapter 49 Documentation and the Nurse Care Planning Process Rockville Maryland NCBI Bookshelf

bull Why Have Nursing Care Plans (2011 February 17) Retrieved from RNcentral httpwwwrncentralcomnursing-librarycareplansWhy_Have_Nursing

bull Etolen N (nd) Priority Nursing Diagnosis Retrieved from eHow httpwwwehowcomabout_5409228_priority-nursing-diagnosishtml

bull Lake S Moss C amp Duke J (2009) Nursing prioritization of the patient need for care A tacit knowledge embedded in the clinical decision-making literature The International Journal of Nursing Practice 15 376-388

bull Steps To Creating A Priority List (nd) Retrieved from httpwww2sunysuffolkedumccabesNR3320priority20List

bull The Joint Commission (2015) Comprehensive accreditation manual for hospitals The officialhandbook Oakbrook Terrace IL The Joint Commission