Case Review and Plan of Care

POLICY

An appropriate professional will review the plan of care at least every three months and revise it as necessary to meet client needs.

PURPOSE

To ensure that the client’s needs are met adequately and appropriately.

PROCEDURE

• The plan of care is established in collaboration with the client, based upon the findings from a comprehensive assessment.
  1. The plan is reviewed at least every three months by the appropriate professional.
  2. The plan of care is revised as needed based on changing client needs.
• If physician orders are needed for the services provided by the agency, a home care health professional will notify the physician of any changes in the client’s conditions, which indicate the need for altering the plan of care.
• As long as the client is receiving hands-on care, an appropriate professional will visit the client in his residence, at least quarterly, to assess his/her general condition, progress, and response to services provided.
• The plan of care is modified in response to findings during home visits.
• Documentation of these visits is entered into the client’s service record by the professional who makes the home visit.
• When the same professional is assigned responsibility for multiple functions, the following functions may be conducted during the same home visit:
  1. Quarterly assessment of the client’s condition and response to services
  2. Provision of regularly scheduled professional services
  3. Supervision of in-home aides or other allied health personnel

GUIDELINES FOR NOTIFYING MD

POLICY

To ensure all patients have access to their physicians in medical emergencies, the name, phone number, and after-hour contact information of the physician will be readily available.

PROCEDURE

All home care staff are required to notify the patient’s attending physician promptly of:

• A sudden or marked adverse change in signs, symptoms, or behavior
• An unusual occurrence involving the resident
• A change in weight of five pounds or more within a 30-day period
• An untoward response to a medication or treatment
• A life-threatening medication or treatment error
• A threat to the patient’s health or safety that is caused by any circumstance that prevents a timely procurement or administration of prescribed drugs, equipment, supplies, or services

If any of the above situations arise, the caregiver shall call the nurse supervisor that is followed by the patient’s physician on record, including but not limited to calling the after-hour number on file.

If unable to contact the physician on record, immediately call 911 should the patient’s condition deteriorate.

Notify immediate family member(s) on file.

Document all actions taken.

GUIDELINES FOR CHARTING AND DOCUMENTATION

Each registered nurse is expected to complete written and/or electronic documentation in a manner that is clear, timely, accurate, comprehensive, legible, chronological, and is reflective of relevant observations.

The agency’s nurses must follow and be familiar with the agency’s documentation policies, standards, and protocols. All documentation shall be:

• Factual
• Accurate
• Complete
• Current (timely)
• Organized
• Compliant with standards

Clear, complete, and accurate nursing documentation facilitates quality improvement initiatives and risk management analysis for clients, staff, and organizations.

Through chart audits and performance reviews, documentation is used to evaluate the quality of services and appropriateness of care.

The client’s record is a legal document, which can be used as evidence in a court of law or in a professional conduct proceeding.

Documentation can be used by administrators to support funding and resource management.

Through chart audits and performance reviews, documentation is used to identify the type and amount of services required and provided as well as the efficiency and effectiveness of those services.

Workload measurements and/or client classification systems, derived as a consequence of client documentation, are used by some agencies to help determine the allocation of staff and/or funding.

EDUCATION GUIDELINES FOR PATIENTS

The agency’s RNs provide a wide range of client education on a daily basis. Accurate documentation of this education is essential to enable communication and continuity of what has been taught. Lack of documentation about client education diminishes this important aspect of care. The following aspects of client education should be documented in the health record:

• Both formal (planned) and informal (unplanned) teaching
• Materials used to educate
• Method of teaching (written, visual, verbal, auditory, and instructional aids)
• Involvement of patient and/or family
• Evaluation of teaching objectives with validation of client comprehension and learning
• Any follow up required

For more information, please feel free to contact us at your convenience.