Provider Plan of Care is developed by the physician or other licensed independent practitioner and is reflected in provider orders and progress notes. Nursing Plan of Care Nursing Plan of Care Developed in conjunction with the provider plan of care and orders. Individualized with priority problems and established goals and interventions Nursing Priority Problems Nursing Priority Problem Outcomes Based on the structured Clinical Care Reflect realistic discharge outcomes Classification® terminology and reflect: (select one): Patient’s priorities [pain, nutrition] Improve Support Recovery [fracture – Actual or potential problems that can will heal] be diagnosed independently by Stabilize Chronic [asthma, heart failure] – nursing [safety, skin integrity risk] Support Decline [ESRD, palliative care] Significant deviations from the overall multidisciplinary team plan of care Note no longer a priority, –when [cardiac output, gas exchange, problems are ended, with outcomes stated balance] (improved, stabilized, decline supported) Priority Problem Short Term Goals are established every shift for the current shift’s Priority Note: day and night shift may have different priorities (ambulation versus Problems. sleep). Plan Priorities are used to communicate the patient’s plan of care and are part of an optimal handover when a change in caregiver occurs. It is a statement regarding interventions that were effective, new problems, and/or recommendations for the next caregiver (e.g., continue q4h Percocet, reinforce ambulation) Nursing Summary is a concise, overall summary of the patient’s response to care interventions (VSS, pain=2 on Percocet) and any significant events that occurred Documentation Systems: HED Horizon Expert Documentation™ is the current inpatient nursing documentation – system in which the nursing plan is documented and then displayed in StarPanel™ (electronic health record [EHR]). This same application is used in the Peds Emergency Department. VPIMS is the Perioperative documentation system WITT Cardiac Cath Lab documentation system Order Tracker is the Emergency Department (ED) order tracking system and includes some nursing documentation. racking system and includes some nursing documentation. . ation is done on StarForms. In the Peds ED nursing documentation is StarForms, one of the documentation tools available in StarPanel, are used for nursing documentation in the Adult ED.
Provider Plan of Care is developed by the physician or other licensed independent practitioner and is reflected in provider orders and progress notes. Nursing Plan of Care Nursing Plan of Care Developed in conjunction with the provider plan of care and orders. Individualized with priority problems and established goals and interventions Nursing Priority Problems Nursing Priority Problem Outcomes Based on the structured Clinical Care Classification® terminology and reflect: Patient’s priorities [pain, nutrition] Actual or potential problems that can be diagnosed independently by nursing [safety, skin integrity risk] Significant deviations from the overall multidisciplinary team plan of care [cardiac output, gas exchange, balance] Reflect realistic discharge outcomes (select one): Improve – Support Recovery [fracture will heal] Stabilize – Chronic [asthma, heart failure] Support Decline [ESRD, palliative care] Note –when no longer a priority, problems are ended, with outcomes stated (improved, stabilized, decline supported) Priority Problem Short Term Goals are established every shift for the current shift’s Priority Problems. Note: day and night shift may have different priorities (ambulation versus sleep). Plan Priorities are used to communicate the patient’s plan of care and are part of an optimal handover when a change in caregiver occurs. It is a statement regarding interventions that were effective, new problems, and/or recommendations for the next caregiver (e.g., continue q4h Percocet, reinforce ambulation) Nursing Summary is a concise, overall summary of the patient’s response to care interventions (VSS, pain=2 on Percocet) and any significant events that occurred Documentation Systems: HED – Horizon Expert Documentation™ is the current inpatient nursing documentation system in which the nursing plan is documented and then displayed in StarPanel™ (electronic health record [EHR]). This same application is used in the Peds Emergency Department. VPIMS is the Perioperative documentation system WITT Cardiac Cath Lab documentation system Order Tracker is the Emergency Department (ED) order tracking system and includes some nursing documentation. racking system and includes some nursing documentation. . ation is done on StarForms. In the Peds ED nursing documentation is StarForms, one of the documentation tools available in StarPanel, are used for nursing documentation in the Adult ED.
CL%2030-05%2001%20Plan%20of%20Care%20%20%20%20Final%20DRAFT%204-12-12.docx