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. PROBLEM Outcome 1 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. PROBLEMOutcome 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. Red63.

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 bottom of the screen are activities you can perform. You can click on these buttons to carry out a task.

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

14. 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

15. 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.

16. 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 Enter button.

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

18. 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.

19. 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, click Enter to add the Med Surg care plan. Click Enter twice to accept the default date and time of Today and Now.

20. Click Problem Detail button at the top of the screen. Now you can individualize your care plan for your patient-add or delete problems. Save.

21. Delete a problem that is not applicable to your patient. Choose a problem to delete. Highlight and click delete. Press Enter.

22. To add a problem: Arrow down to a blank line in the Problem section. Press the F9 key to view additional problems. Select an additional problem. Click green check to Save.

23. The problems are already prioritized. You can only prioritize up to 9 problems. Use the Edit button, the Prioritize Problems to edit the priority of the problems.

24. Click in the Priority New column and change priorities. Click the Green check to “Save”, then click the X to escape.

25. 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.

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

27. 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.

28. PROBLEMS INTERVENTIONS

29. 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.

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

31. 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.

32. We used the Process Plan button to select and modify the care plan for our patient. We will use the Outcomes button to document and edit our patient’s progress toward their care plan goals. We will click on Outcomes now.

33. This is the Document Outcomes screen. Let’s discuss the components of this screen.

34. The first column lists all the problems that were added when we initiated our patient’s care plan. Our patient has five problems. The problem with the highest priority will appear at the top of our list of problems. The lowest priority problems will appear near the bottom.

35. The next column is similar to the blank column on our Interventions worklist screen. You can place a check mark in this column to select more than one outcome at a time. This is useful when documenting on several outcomes or when you want to change the status of several outcomes at once.

36. The next column is the text column. You can click in the text column to add or edit text attached to an Outcome. Remember that any text you add will become a part of the patient’s permanent medical record, so we only want to use this feature for professional communications.

37. Every problem will have at least one Outcome attached to it. Outcomes are the clinical goals for our patient. We want our patients to progress towards their expected outcomes during their hospital stay. We will double click on an outcome to document our patient's progress towards that particular goal.

38. Every outcome needs to have a target date. Target dates specify when we expect the patient to be meeting the outcome goal. If a outcome does not have a target date we must add one before we will be able to document against the outcome.

39. This screen also has a Status Column. Just like on our Intervention worklist, if we have a patient who has met an outcome, we can change the status to complete and it will no longer show on our Outcomes documentation screen. An outcome with an Active status means the patient has not met the goal and is still progressing towards meeting it.

40. This History column will show us when the outcome was last documented on. This time can be in minutes, hours, or days. Hospital policy is that we document on our care plan outcomes at least once per shift or once every 12 hours. This documentation is typically done near the end of your shift.

41. If there is a protocol attached to an outcome, it will appear as a triangle on a gray background within the Protocol column. To view the protocol, you will click on the triangle and the protocol will open on your screen.

42. The final column on our Outcomes screen is the Associated Data column. If there is any additional information that is available to help you document your outcomes, it will be linked through this column. If information is available, it will appear as a triangle on a gray background. To view the information, you can click on the triangle symbol and the information will open on the screen.

43. You will use the Document Outcomes routine to manage the outcomes that were generated by the care plan. You will recognize outcomes from the plan you just filed here. Note that all but one has a target date already filled in for you. Target dates are generated when the care plan is created, based on average patient outcomes for the disease process you selected.

44. Target dates will generally be estimated from one to four days from the patient’s date of admission. Since every patient is different, you are responsible for adjusting these dates to make them reasonable goals for you patient.

45. The first thing we notice is that one problem we added does not have a target date. Before we can document on this outcome, we need to give it a target date. All we need to do is click in the blank space in the target date column. Let’s do that now.

46. The calendar entry pop up box will appear. We will choose the appropriate date from the calendar. Using the assessment data you collected, you have determined that the patient’s fatigue can be resolved with a target date of tomorrow, which in tutorial time, is April 6th. In order to make that selection, we will have to click on the correct date in the pop up window.

47. Now the correct month is highlighted at the top of the window. We have clicked on the 6 th so that it is highlighted for us. Now we can click on OK to fill in the target date for this outcome.

48. We can see the new target date reflected in the Target Date column with a green background. This reminds us we need to Save. Let’s click on Save now.

49. The new target date has been saved. We will now be able to document on this outcome.

50. Now that the target dates have been adjusted, the care plan truly is complete. You have added the necessary elements, removed those which do not belong and have adjusted the target dates to coincide with reasonable patient goals during hospitalization. Now your responsibility turns to monitoring your patient’s progress toward the expected outcomes.

51. Documentation on outcomes must be filed every 12 hours during the patient’s hospitalization, whether or not the outcomes have been met. To document the outcomes, we can double click on them or click on them once so they are highlighted and then click on the word Document.

52. Let’s use the Pain outcome as an example.To begin documenting on it, we can double click on the outcome, or click on it once to highlight it then click on the Document button.

53. This will open the date/time window. We will click on OK to advance to the Care Plan Outcome documentation screen.

54. There are guidelines listed in the answer box in blue text to help you determine whether the outcome has been met. This patient’s pain outcome, according to these objectives, has not been met. We will document that now by clicking on the Not Met selection. Guidelines

55. When the outcome has not been met, always enter a comment to explain why it has not been met and what is being done to accomplish the prescribed outcome. We will need to enter a comment for this outcome.

56. Here we have entered information that describes the patient’s pain and his progress towards the resolution of the outcome. The comment may be brief, but descriptive, like this one.

57. By now, you know that you need to save your work in order for it to be documented. We will do that now using the Save button.

58. Now let’s experiment with documenting an outcome that has been met. We will double click on the impaired mobility outcome to get started. Remember to click on the light gray area that is the outcome, not the problem title.

59. The patient’s diarrhea is resolved, so the outcome has been met. We will document that now and press Save to save our documentation.

60. When an Outcome is met and is not an ongoing process such as the “Free of Complications of Immobility” outcome, it no longer needs to be monitored. You learned in another lesson that interventions are completed when they are no longer needed. The same is true for outcomes. To change the status of an outcome that has been met, you can click in the Status column for the intervention or click on the Edit Status button.

61. We will click in the Status column for the impaired mobility Problem now to change the status from active to complete.

62. From the pop up menu that appears, we will click on the word Complete.

63. You will then be asked to verify if you want to change the status of the outcome. We will click on Yes here.

64. Once again, we see the color purple, reminding us to save. We will click on Save now to save our status changes.

65. Finally, let’s look at how to document an ongoing outcome. The “Remains Free of Infection” outcome is a good example. When your patient has met this outcome, it’s not as though you stop ensuring that he remains free of infection, so this outcome is known as an “Ongoing” outcome. We will begin documentation of this outcome as you did the others, by double clicking on it.

66. Again the guidelines that describe what constitutes the outcome having been met appears in blue text in the answer section of the screen. We will document that this outcome is Met and Ongoing now, then save it and return to the Document Outcomes screen. No Goal Progress Text is required for this ongoing outcome.

67. We can tell by looking in the History column that we have documented some of our outcomes. Care givers will document outcomes every 12 hours for each patient. Care plans are typically documented at the end of the shift. All admitted patients must have a care plan created for them.

68. A care plan cannot be a static document. It naturally must change to meet the changing needs of the patient. Now let’s take a look at how you will go about modifying the plan as your patient’s requirements evolve.

69. The day after you created the care plan your patient is complaining of feeling overwhelming anxiety about his hospitalization. This is a new problem that needs to be addressed by the care plan. You can add the new problem using the Process Plan button. We will click on the Process Plan button now.

70. You learned about the Process Plan screen when you initiated the care plan earlier in this lesson. Now let’s look at how you can use this screen to modify the existing plan. Your task is to add the anxiety problem to the patient’s care plan. We will start by clicking on the Enter button.

71. This time, rather than selecting the Care Plan option from the drop down menu that appears, we will select the Additional Care Plan option. The Additional Care Plan option will allow you to add the new problem our patient is experiencing.

72. This opens a multi-purpose screen on which you can enter new problems. When you arrive on the screen the cursor is blinking in the Intervention section. We are adding a new problem, so we need to click on “Problem Details”.

73. Our patient’s problem is anxiety. Problems that belong to the Psychological group are all prefaced with the letters “PSY.” Since you are looking for the Anxiety problem, we will type PSY in the problem section of the screen and press Enter to add the PSY problem.

74. The list of problems that begin with”PSY” appears, and the anxiety problem is second on the list. We will choose it now by clicking on it.

75. The problem has been selected and added to the Problems list for you. You need to file the addition to the care plan by clicking on the green checkmark on the panel menu.

76. The new problem appears under Additional problems/interventions, rather than as a part of the Medical/Surgical care plan above it. Note that this new problem does not yet have a priority, so you would need to enter one. Since you already know how to do this, we will do this piece for you.

77. We can now see the priority in the priority column and we are ready to leave this screen.

78. We will now click on X to get back to outcomes screen.

79. Now we are back on our Outcomes screen. We can see the new problem and outcome that has been added to our patient’s care plan.

80. We have added a target date to our new problem, and it is ready to be documented on.

81. If you ever document an outcome in error, you need a way to correct your mistake. To undo outcome documentation, we can click in the History column for the outcome we wish to change.

82. Let’s pretend we documented the Remains Free of Infection Outcome on the wrong patient by accident and we wish to undo the documentation. We will start this process by clicking in the history column for this intervention.

83. This will open a screen where we can see all of our past episodes of outcomes documentation. To Undo documentation entered in error, we have to click on the episode of documentation so that the row is highlighted green (as seen above), and then click on the Undo button at the bottom of the screen.

84. Clicking on Undo will open a screen where you must select a reason why you wish to undo the documentation. Here we have selected the Incorrect patient choice. Now we will click on OK.

85. Now we can see a new line has been added to our screen. We can see the word Undo in the last column with a green background. The color green reminds us we have to Save. We cannot save from this screen. We must click on the Return button to get back to our Outcomes screen.

86. Now we have returned to our Care Plan. We can see the new line of purple text underneath the outcome that we just changed. To save our changes, we will click on Save.

87. Our changes have been made, and we will no longer be able to see the outcome documentation that we just “undid” in the Open Chart / EMR.

88. We can also edit previously documented outcomes. Let’s pretend we just realized that we documented our patient’s Respiratory outcome as being Met and Ongoing, when in reality, our patient is not meeting their respiratory care plan goal.

89. We will first click in the History column for this outcome to view our previous documentation.

90. This will open up the screen showing all of our previous outcome documentation. We will select the appropriate row and double click on it now to make our changes.

91. This has opened the screen showing our past documentation. We will make our changes to this screen now – switching our outcome from Met and Ongoing to Not Met with a comment.

92. Now that we have made our changes, we will click on Return.

93. We have been returned to our edit screen. We can see our changes have not been saved yet, as evidenced by the new edit line that has been added with a green background. Once again, we will click on the Return button.

94. We have been returned to our Outcomes documentation screen. Now we will save our changes by clicking on Save.

95. We have learned how to add a care plan to a patient, how to document on the care plan, and how to make changes to the care plan. We are now finished and will log out of Meditech by pressing the Exit PCS button.

96. Almost there! Now we will click on the X to log all the way out of the system.

97. Great Job!! SUMMARY The holistic Plan of Care consists of Standards of Care interventions, the care plan, and nursing orders. To choose a care plan or add additional problems to a Care Plan, click on Process Plan from the Status Board. Select a plan based on the type of patient admission, individualizing the plan by adding and deleting problems as needed. Assign a priority to new problems and organize preset priorities based upon your analysis of the patient’s needs. Document Outcomes at least every 12 hours. Every outcome must have a Target Date which you define. Correct errors in outcome documentation using the History column.