Individualized Plan of Care: Changes in Process & Documentation

Best Practice

• Evidence based Clinical Pathway for a patient population used as basis for plan; if such a pathway is not available, age-appropriate generic pathway should be used

• Individualized to a specific patient• ALL members of team contribute (Patient/family, Provider,

Nurse, Soc. Wk., Therapists, Dieticians, Child Life, others)• Reviewed regularly, revised with change in patient status• Focus on significant, priority problems • Reflects progress towards measureable outcomes• A practical tool to help the team coordinate care, evaluate

the effectiveness of treatment, and patient’s progress

Current and Proposed Processes -- in BriefCurrent Process

• Admission: Print Paper Pathway from E-Docs; retain in paper chart (w/ or w/o written updates) Reflect individualization by: – Updates to Pathway (paper)– Nurse-entered orders (HEO/Wiz) – Documentation on Plan of Care Tab (HED) – Documentation by other team members (StarPanel

and paper)

• Q shift/Q24h (per unit stnd.) POC review/revise: – Document status/revisions on paper pathway &/or in HED

(Name of Pathway, Pathway Phase, Status, Why Goals Not Met, Action, Plan)

• With handovers – review POC (Pathway, Phase, Status)

• Discharge – same as handovers plus if any unresolved issues, must document plan to address post discharge.

• Monitoring – requires audit of paper chart and HED

Proposed Process• Admission: Select Pathway & save to Patient

Electronic Medical Record (EMR )in StarPanel. Reflect customization by documentation in HED (Nursing). Electronic documentation from all disciplines accessible in StarPanel & aggregated in OPC view.

• Q shift/Q24h (per unit stnd.) POC review/revise: – Review documentation by other team members and

Pathway (StarPanel OPC); consider assessment data and input from patient and family.

– Document: • Name of Pathway & Phase (if new, changed) (HED)• For each significant problem, review/revise as

needed expected outcome & document status towards expected outcomes (HED)

• Document summary of patient’s status in Nursing Summary & highlight issues of concern in Priorities/Plans (HED)

• Handovers: Use OPC to review Pathway, significant, priority Problems, Expected Outcomes, Status, Nursing Summary, Priority & Plans (StarPanel OPC)

• Discharge: Same as current process. • Monitoring: Electronic reporting from HED

Admission Process• Complete Admission History in StarPanel & initial Assessment in

HED (same as current process) • From StarPanel, select best pathway for patient. Save to StarPanel.• Based upon clinical assimilation of your assessment, patient’s

history, pathway, orders, patient/family input, & multi-disciplinary input, identify and prioritize most significant problems and document in HED. (At least 1 problem and no more than 3-4 problems at a time!)

• For each problem, identify an expected outcome. Each outcome should be: – Specific– Measureable– Outcomes should represent patient behavior/status rather than a task

a team member will complete (i.e. “Pt. will demonstrate ability to change ostomy bag without assistance by POD #3” NOT “Pt. education on ostomy care done by POD #3”)

Daily/Q Shift (per unit standard)

Review/Revise Plan of Care by:• Review Pathway; based on goal attainment for the current Pathway

phase, determine if the patient will remain, progress, regress to a different Phase. Following initial Pathway documentation, you only need to document changes in Pathway or Phase.

• Review orders; verbal & written input from team, assessment, rounds, & patient/family as basis for evaluation of patient progress toward expected outcomes & identification of new problems.

• Document actual outcomes of current problems. Adjust expected outcome as patient’s status changes.

• If priorities have changed, end lower priority problems and add higher priority ones.

• Enter nursing orders for new interventions if the interventions are not already included on Pathway or Current Orders.

• Interface with other disciplines as patient’s condition warrants.

Use OPC to view team

documentation

With Handovers (change in care provider, level of care, unit transfer, etc.)

• Use OPC to review Plan of Care and Priority Problems with receiving Nurse

Click on Pathway Name to View

Other Functionality of the OPC • OPC = Overview of

Patient Care • Ease of access to

Multidisciplinary Data• Current Orders• Hyperlinks for Details• Team Pager Hyperlink• Family Contact Info• Trends VS & I&O’s• Excellent tool for

handovers – print in lieu of Current Order Sheet

Upon Discharge

• Review Pathway, orders, input from patient family, & team, status of expected

outcomes for each active problem. • Document status of each problem. • Annotate plan for post discharge follow-up for

priority problems that are not resolved by discharge.

Customize Action Box1. To Add E-docs Pathway and OPC v.22. Click on Actions then click Customize3. Click on desired items (turning them blue)4. Click Install New Actions

To Select Clinical Pathway1. Action Box – click on E-docs Pathway2. Check Peds or Adult – Enter text in Search to narrow selection options3. Scroll through list to find Pathway

Click on E-docs Pathway

Select & Save Pathway to EMR1. To view Pathway – click on “view” 2. Can Print Education Documents from this screen3. To Select Pathway click on Pathway Name4. Add to Pathway by clicking on “OK” 5. Confirmation Screen that Pathway was added

OPC – To View Patient’s Pathway Click on Pathway Name to Open &

View

HED - Plan of Care/Dschg Plan Tab

Enter Pathway Name & Phase1. Initially document Pathway and Phase2. Upon Review of POC, only document changes in Pathway or Phase

Click “Start New Problem”

Adding Problems

Expected Outcomes 1. Patient specific2. Measurable3. Represent patient behavior/status (what the patient will

achieve not a nursing task) 4. Enter brief text description of Expected Outcome

Actual Outcomes1. Rating of patient’s progress towards expected outcome:

• Met Expected Outcome• Improved• Unchanged• Worse

2. When first documented an expected outcome for new problem, SELECT “initiated” as the Actual Outcome

Click Type & Select from Drop Down List- adding comment is optional

In date field, type “T” to load today’s date

Daily/Shift Documentation: Pathway Name, Phase, Nursing Summary, Plan/Priorities

New Fields

Nursing Summary

• Brief statement that summarizes and assimilates clinical data & events for shift

• Document toward end of shift (prior to 0500/1700) & upon Transfer

• Keep it brief & concise – 240 character limit• Feeds into the Charge Nurse Snapshot as your

summary of shift

Plan & Priorities

• Replaces “Plan & Action” in Plan of Care• Complete with Nursing Summary• Your recommendations for the plan &

priorities for the oncoming nurse• Examples: Ambulate in hall; Suction q3h;

Vanc level due @ 10am; CT scan @12pm• Keep it brief & concise – 240 character limit

Daily/Shift Documentation: Update Expected & Actual Outcomes

Initiated, Met, Improved,

Unchanged, Worse

Add or End Problems as Clinically Indicated

To End a Problem1. In field of problem to be ended, click on Magnifying Glass2. Under End a Problem, click in the date field, type “T” for Today3. Adding a comment is optional4. Click Save

Click on Magnifying Glass - opens End

Problem Box

If there are more than 4 Active problems …

Lower priority Problem will not be significant focus at present time

3-4 most significant Problems will be focus at

any point in time. Use significant flag for the Expected Outcomes to

denote these if there are > 4 active problems

Document against significant priority Problems at least once each 24 hrs. In this example, you’d chart against Problems

circled in green but not against those circled in red.

Example of Daily Problem &Expected Outcome Update

Hover to View HED Documentation

Hover Over Field – Pop-up Box will display

data last entered for this field

Resources 1. Helpful resources are available via HED2. Click on Links in HED and select the option of your choice3. Mosby’s Nursing Consult offers helpful info re: Plans of Care

Resources in StarPanel: Mosby’s Nursing Consult

1. Click on Inf. Resources2. Click on Resources 3. Click on Nursing Res.

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Mosby’s Nursing Consult includes the SKILLS section we use as our procedure manual plus much more. For help with

planning care for patients w/unfamiliar disease processes, check the Evidence-Based Nursing section for

monographs. There are links to Mosby’s from HED links & StarPanel

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