1. Creating the Care Plan PCS Lesson Five

2. OBJECTIVES Following completion of this lesson you will be able to: • Demonstrate how to select a care plan • Identify the parts of the care plan • Demonstrate how to tailor the care plan to the patient’s needs • Demonstrate how to navigate in the Process Plans of Care routine • Describe Outcomes documentation and demonstrate how to document outcomes as met, not met and ongoing • Demonstrate how to correct an outcome entered in error

3. You began the documentation process when you received the patient and added a Standard of Care (SOC). Collecting assessment information allowed you to discover more about this patient’s individual needs for care while a patient at GBMC. Creating a care plan will provide you with a list of nursing problems and a measurable set of desired outcomes with associated target dates. Developing the patient’s care plan is the next logical step in the admission process. Later you will monitor the patient’s progress and adjust the care plan as needed to move the patient towards discharge.

4. Our documentation system has generic care plans that make it easy for you to create a plan of care for your patient. It is up to the nurse to review the care plan for appropriateness and to make sure it is up to date and includes all applicable problems. In this lesson you will create a care plan and edit it to add what is missing and take away what does not belong. You will learn how to customize the care plan to perfectly match the patient’s individual condition.

5. A care plan is basically a list of problems. Each problem will have at least one outcome associated with it. The outcomes are the goals you will strive to reach in order to resolve the problem during the patient’s stay. Outcome 1 PROBLEM Outcome 2

6. For each of the problems and associated outcomes, there will be a pre- programmed target date. This target date represents the date that it is expected the problem should be resolved. It is important to advance the target date if the patient has not met the expected outcome by the designated target date. PROBLEM Outcome 1

7. Now that you have a basic understanding of the care plan structure, you will select one for your patient. While this is a medical admission, and the plan may be different from those which you use on your unit, the processes are the same.

8. You will add a Care Plan in PCS. Let’s start by clicking on the PCS Worklist Icon on our desktop.

9. The Status Board represents the patients that are currently assigned to you for your shift. You must first select a patient for whom you want to create a care plan. Our practice patient today is Mr. Red.

10. With the patient for whom you want to build a care plan selected, you are ready to start. To initiate a care plan, click on the Process Plans button on the panel menu.

11. This is the Process Plans of Care screen, where you can view your patient’s holistic plan of care. Note that the interventions that were created when we selected the Standards of Care appear on this screen. The Standards of Care Interventions, Care Plan, and Nursing orders from the Order Management routine all make up your patient’s total Plan of Care.

12. Before you select a new care plan, let’s take a closer look at the different parts of this screen. The icons at the top of the screen are activities you can perform. You can click on these buttons to carry out a task or you may also use the keyboard to type the letter ‘E’ or ‘P’.

13. The “E” button lets you enter a new care plan or add another problem to an existing care plan.

14. The “P” icon is used to prioritize the problems identified in the plan according to their importance or to stop a care plan.

15. The section under the Enter and Priority buttons is the patient identification header which displays the account number, name, age, sex etc. Always confirm to make sure you have the correct patient before adding or changing a care plan

16. At the bottom of the screen is a list of all interventions that have been added to this patient’s plan of care from the Standards of Care selection that was made upon the patient’s admission. The “I” in the Type column indicates that these are Interventions that originated from the Standard of Care.

17. Now, let’s add a care plan specific to the type of care provided on a Med/Surg unit. To select a new care plan, we will click on the E button or type the letter E.

18. A menu appears with two selections. To create a new care plan, we will click on “Care Plan”.

19. Note the cursor is blinking in the Plan of Care field, waiting for us to choose an appropriate care plan for the needs of this patient. Care plans are named according to the type of patient admission - Med/Surg (MS), Pediatric (PED), Newborn (NBN), Postpartum (PP), NICU (NIC), etc. Critical Care patients get the Med/Surg care plan added, as there is no specific care plan created for critical care patients.

20. Our patient is a Med/Surg patient. To efficiently access a list of only Med/Surg care plans, we have typed MS in capital letters. Next, we will click on the Binoculars on the right toolbar or press the F9 key on our keyboard.

21. You have narrowed the list of care plans down to those starting with MS. Here Med/Surg is already highlighted because it is first on the list. To select a care plan, we can double-click on it, or click the green check mark while it is highlighted. We will select Medical Surgical using one of these methods.

22. The Care Plan title now appears with an Active status. Notice that day one is automatically filled in with the current date. For this lesson, today’s date is 3/30/06. We will press the Enter key on our keyboard to to accept this information.

23. The start time will always default in as the current time. Accept the time as it is displayed by pressing the Enter key.

24. Here is the list of problems that make up the Medical Surgical plan. Only three problems can be displayed at once, so you must scroll down the list in order to view all the problems included. To scroll downward, you will use the down arrow key on the keyboard.

25. Before you save the care plan, review the problems to determine whether they fit the patient’s needs. Having reviewed the problems presented in this care plan, you have decided that impaired mobility is not a high risk for this patient and you want to delete that problem. To delete a problem you must first position the cursor on the appropriate line. Using our arrow keys, we will now scroll down the list to the Impaired Mobility problem.

26. With the MS.MOB problem highlighted we are ready to delete the problem from this patient’s care plan. To do this, we will press the Delete key on our keyboard.

27. You can see that the code is gone but the description of the problem is still displayed – “High Risk: Impaired Mobility.” You will press the Enter key to completely remove this problem from the list.

28. Note that Impaired Mobility is now removed and the additional problems have been moved up on the list. The patient’s problem list now includes just four problems.

29. Just as you should remove problems that do not apply to your patient, you must also be able to add new problems that were not included in the generic care plan. Let’s suppose your new patient has diarrhea. This problem is not included in the care plan, so you need to add it.

30. To add a new problem you will always start on a blank line, so we have arrowed down to the end of the list for you. Again you will use the lookup function (binoculars or the F9 key) to select the appropriate problem for you patient.

31. Problems that are associated with Med/Surg patients begin with MS. To perform the lookup, type the letters MS and then click on the binoculars or press the F9 key on your keyboard.

32. Here is the list of all problems that are prefixed with “MS.” To find the diarrhea problem you need to scroll down so that you can see more selections. Click on the bottom of the scroll bar to move downward now.

33. Now that you have located the problem you must select it. There are two ways to select: you may double-click on the entry, or click once on it to highlight and then click on the green check mark.

34. This screen shows that you have added the selected problem to the patient’s list of problems. But the process is not quite complete yet. Until you file the care plan, the changes that you have made will not be saved. We will file the care plan now by clicking on the green check mark on the toolbar. The keyboard equivalent of the green checkmark is the F12 function key.

35. Meditech will always offer you a second chance, to make sure you really want to file the care plan. We will confirm that we are ready to file by clicking on the Yes button now.

36. Now we are back to the Process Plan of Care screen. You will notice all of our care plan problems have been added at the top of this screen.

37. Now that you have added a new problem to the patient’s list you need to assign a number value, or priority, to it according to its importance in the patient’s plan of care. Assigning a priority is a subjective judgment that you make based on the patients’ assessment data. To prioritize the problems, use the Prioritize (P) icon at the top of the screen.

38. We want to prioritize our problems, so we will click on the Prioritize Problems option.

39. The Prioritize screen is where you can order the problems in the care plan according to their importance. Each problem appears by name and its “old” priority appears in the second column, circled here.

40. The “New” column is where you can change the priorities to reflect their order of importance for your patient. Let’s accept the old values and add a priority for Diarrhea, which is the new problem you just added. To do this we will click once in the ‘New’ field next to the problem, Diarrhea.

41. The Mobility problem that you deleted had a priority of 3. You feel that the new Diarrhea problem should also have a priority of 3, following pain and altered respiratory function in order of importance for this patient, so we will enter that now.

42. Now we are ready to save our new priorities. To File them, we will click on the green check mark now.

43. A screen appears asking you to confirm that you wish to save this plan of care. We will click on Yes or type Y to file the modified priorities.

44. You can now see the new priorities on the Process Plans of Care screen in the Pri column.

45. You can differentiate the problems created by the care plan from the interventions that came from the Standard of Care because have different letters in the Type column.

46. PROBLEMS INTERVENTIONS

47. The Care Plan initialization that you have just completed includes these steps: 1. Select the plan. 2. Delete the problems that do not apply. 3. Add any additional problems your patient is having. 4. Assign a priority to problems that were added to the care plan. 5. Save the plan.

48. Now we will exit the revised care plan using the red X on the toolbar, as indicated here.

49. Meditech confirms that you want to exit. In this case the Care Plan has already been filed, so it is okay to exit now. We will click Yes or type Y.

50. You have learned how to create a care plan and how to select the appropriate problems and outcomes for your patient. Now we need to learn how to document our patient’s progress towards meeting his/her care plan goals.