Care Planning in Documents

CAREpliance is designed to greatly simplify the process of creating and editing care plans for both clinicians and office agency personnel. Aside from the Care Plan tab that provides direct access to the patient’s active care plan, users are able to edit the care plan without ever leaving the assessment document.

 

Visit Dates in Enhanced Documents

Each care plan is centered on the visit date associated with the document and details are synchronized accordingly. A Visit Date must be present (in the header of the document) before users are able to view care plan details (Sample image, below). Users are prompted to enter a Visit Date any time an enhanced is created in Patients | Documents. This functionality ensures that each patient’s care plan is consistent throughout the agency database for all users and only includes active care plan elements (i.e. Problems, Goals, Interventions).

 

Creating a Care Plan in a Document

Throughout each CAREpliance document, various questions have the potential to trigger Problems, Goals, and/or Interventions (PGI) for the patient’s care plan. An interactive “Problems, Goals, and Interventions” section will display underneath applicable sections. Refer to the “Using the Problems, Goals, and Interventions Sections” part below for information about these features.

When using CAREpliance documents, users have the freedom to determine which approach they want to take when completing assessments and interacting with care plan data:

●     Proceed through the entire document and, in each instance of the interactive Problems, Goals, and Interventions section, use the “View Recommended Problems” option to select the appropriate care plan elements. Repeat this process until document is complete.

●     Select only care plan elements that are needed for the current visit. For instance, in some situations, the clinician may arrive at the patient’s home and they are unable to stay. This

●     allows them to complete only the necessary tasks (e.g. Taking vital signs, treating wounds, etc.)

●     Proceed through the entire document and only answer assessment questions. After all assessment information is entered, either use the “Modify Care Plan” option in any of the interactive sections (or click on the Care Plan tab) to construct and generate a care plan for the entire visit.

 

CAREpliance Documents that are Completed

Interactive functionality will become disabled for documents that are completed, locked, and signed and the Actions features will be removed. Additionally, users will not be able to use any of the Problems, Goals, and Interventions sections. If they attempt to, a notification will display in red. If the document is unlocked, users can still edit the care plan from within the document.

To ensure the latest information is used, the software refreshes data every time any user opens a document. If a user completes a document (but does not lock it) and then a different user opens it later and adds new information, it will be included with the rest of the assessment data. As long as the document is not opened, the information in the document will remain as is.

 

The primary functionality that enables users to build a care plan from within the document is the Problems, Goals, and Interventions section, which is located beneath any question or response where a Problem, Goal, or Intervention applies. As mentioned, every instance of this section is tied to the Visit Date field (in the document header). When a Visit Date is present, these sections are enabled.

Any applicable Problems, Goals, or Interventions (PGI) will automatically display within the corresponding instance of the interactive Problems, Goals, and Interventions section (e.g. Imminent Status, Medications, Cardiac Status, Pain Assessment, etc.), based on the assessment data that has been entered.

 

Interacting with Problems, Goals, and Interventions in Documents

Users can directly interact with PGI items displayed in any instance of the Problems, Goals, and Interventions section. Each care plan element is marked according to the type of item: “(P)” for Problems, “(G)” for Goals, and “(I)” for Interventions. If applicable, care plan elements are also labeled according to the discipline that is associated.

As seen in the sample image, once a user clicks the Intervention (“SN (I) Mutually develop plan for improving home environment ”), the Intervention expands to display additional fields that are specific to the Intervention. Each care plan element is different and contains functionality that is unique to that element. After all applicable information has been entered for a care plan element, a green checkmark will display to indicate that the Intervention has been performed in the visit.

 

Completing Care Plan Elements

As described in the “Hierarchy of Care Plan Elements” subsection in the Care Plan topic, within each care plan: Interventions are completed or Discontinued, Goals are Met/Not Met, and Problems are Resolved/Not Resolved. This same concept is applied to the actions that users can perform on care plan elements in the Problems, Goals, and Interventions section:

●      — Initiates the Problem Details prompt, which allows users to indicate if the corresponding Problem has been resolved or not. This will automatically mark all Goals as Met/Not Met and Discontinue all Interventions associated with the Problem.

●      — Initiates the Goal Details prompt, which allows users to indicate if the corresponding Goal has been met or not. This will automatically Discontinue all Interventions that are associated with the Goal.

●      — Initiates the Intervention Details prompt for the corresponding Intervention, which allows users to indicate an End Date and discontinue the Intervention.

These prompts are the same "Details" prompts that are described in the "Entering Details for P/G/I" section within the Care Plan Screen topic.

 

View Recommended Problems

Within any instance of the Problems, Goals, and Interventions section, users can click View Recommended Problems to display a Generate Care Plan window that lists applicable PGI available for adding to the patient care plan, based on assessment data. Each instance of this feature will only list PGI items in the Suggested Care Plan that are related to specific section where the View Recommended Problems button is located in the document. Similar with other applications of PGI throughout the CAREpliance features, care plan elements are grouped accordingly.

Initially, only the Problems will display, but users can expand () or collapse () any individual Problem or Goal to view care plan elements that are associated. Additionally, users can use the controls to the top-right of the Generate Care Plan prompt perform an action to all available care plan elements. Users can Select All available care plan elements, Unselect All, Collapse All, or Expand All PGI items that are available.  

Designate PGI items to include in the care plan by checking the corresponding boxes and then entering any necessary information (e.g. Start Date, specifying the discipline, indicate the Intervention Type, etc.). Similar to how some care plan elements contain underscores (____) within the verbiage of the item (in the Care Plan tab), some of the care plan elements in the Generate Care Plan prompt contain “required” fields. For these fields, click required and then enter the appropriate text within the text field that appears.

 

Modify Care Plan

Each instance of the Problems, Goals, and Interventions section also provides users with a direct way to edit the current list of PGI included in the patient’s current, active care plan. Users can click Modify Care Plan to display the Care Plan window, which contains the same exact layout and functionality that is included in the Care Plan tab. This feature provides users with the convenience of altering the patient’s current care plan from within a document so they will not have to alternate back and forth between the document and the Care Plan tab.

For more information about functionality contained in the Care Plan window, refer to the Care Plan topic. While these details focus specifically on the Care Plan tab, the Care Plan window accessed from within documents contains identical features.

At any point while completing a document, users can click Generate Care Plan to generate a care plan based on the latest assessment data that has been entered.

 

When necessary, users are able to indicate if a performed Intervention has not been performed and also reverse any data that has been saved for the corresponding task. As seen in the sample image below, a Not Performed option displays for the “Assess homebound status every visit” Intervention that has been marked as completed for the patient visit.

The Not Performed option will only be available after a user has entered information for the Intervention (and the green checkmark displays).

When a user clicks Not Performed, the Unperform Intervention Confirmation prompt displays. After the user clicks UnPerform to confirm, any existing data for the corresponding Intervention will be deleted.