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Reaching the Standard for Care Plan

By March 5, 2019C&A Blog

A care plan is a tool used to organize and communicate a patient’s care needs, goals
or outcomes to all members of a team based on assessment, reassessment or change
related to diagnosis or testing (PC.01.03.01 EP 1, TJC). It is the documentation that
“tells the story” of the patient’s care throughout the stay. Although care plans can be
documented singularly by separate disciplines such as PT/OT or nursing, there are
also interdisciplinary care plans that can be created by teams during rounding or team
meetings. Interdisciplinary plans have been shown to:

• Decrease the overall length of stay, regardless of diagnosis
• Lower rates of hospital-acquired conditions unrelated to the original diagnosis
• Reduce healthcare-related expenditures
• Decrease overall mortality,
• Lessen the amount of time Foley catheters are in place, and
• Promote faster discontinuation of central lines.1

The foundation for patient care is assessment. Once a patient is assessed, orders are
written establishing a provider’s plan of care. Both CMS and TJC require plans of care
to be established. Nurses, respiratory technicians, physical therapists, discharge
planners, and other disciplines can then take the appropriate orders and establish
interventions to implement plans of care for patients. These interventions are
documented throughout the record. It is important to be able to establish common
areas for this documentation to occur; however, this is not required. Interventions
must exist for each identified problem and should be individualized. An example of
an individualized intervention is, “Elevate patient HOB 45 degrees for intake and
utilize a straw”.

Once the interventions are established, it is important that target dates and goals or
outcomes are documented in the plan. In standard PC.01.03.01 EP 5 states: “The
written plan of care is based on the patient’s goals and the time frames, settings, and
services required to meet those goals”, (TJC). These target dates should not always
be until discharge but should be based on incremental times throughout the patient
stay. With decreased hospital stays surveyors often cite plans that do not have target
dates for implementation of interventions, goals and outcomes. Goals are typically
less defined such as “patient will maintain adequate hydration” versus an outcome of
“patient will have 64 oz of fluids every 24 hours”. Goals and outcomes should be
evaluated and documented as met or not met at intervals appropriate to the
intervention or goal.

Every diagnosis or goal does not have to be evaluated every shift. This has become a
trend with the utilization of the electronic health record. Staff should follow the
hospital’s policy for timeframes for evaluating a goal and determining if it is not met
and document why. If the target date is surpassed, it should be documented that the
goal was not met and establish a new target date. Establishing goals for each shift is
good, but it needs to be communicated if this goal was not met, to continue to be
evaluated and not omitted by the team member that created the goal for that shift.
That could contribute to sporadic care instead of creating a continuum of care.

To demonstrate how a care plan should be completed, a screen shot of a pain care
plan is included. The screenshot demonstrates all the required elements and how they
should be addressed and documented. For example, when selecting interventions,
teach staff to select only those interventions that are appropriate for the patient
based on the assessment. Staff should also be encouraged to further individualize
interventions by creating selections that are not available in the standard set of

In summary, tell your patent’s story. From assessments and orders, establish the plan
with individualized interventions, target dates and goals. Try to document in common
areas so that various disciplines can easily navigate through the chart and explain the
patient’s plan of care. Practice this navigation with colleagues and other disciplines
to review where they document. This practice creates documentation familiarity and
provides the patient with a more concise, targeted and efficient plan of care thereby
establishing a foundation for better communication and a continuum of safe care.
Remember, the care plan should be a living-breathing example of the care, treatment
and services being provided to improve the patient’s outcomes.

1 Interdisciplinary Care Plans: Teamwork Makes the Dream Work,
html, Accessed, Feb 16, 2018.
The Joint Commission E-dition Hospital Accreditation Requirements, Accessed, Feb 16,

Sharon Dills

Author Sharon Dills

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