and management of weight loss in three of (a-b) Ensure all six files reviewed. documentation meets facility and legal Maternity requirements. Include dietary requirements Five client were reviewed. All files evidenced that daily updates to postnatal to the postnatal care plan. care plan and labour/birth infant summary were not completed. 30 days Criterion 1.3.8.2 PA Low Care staff document in progress notes on Two of four short-term care plans reviewed Ensure short-term every shift. Care plan evaluations are did not document evaluation of progress care plans are Evaluations are conducted six monthly. Short-term care towards the desired goal and two had not evaluated to monitor documented, plans have been developed. Two of six been signed off when resolved. progress towards the indicate the short-term care plans from the sample desired goal and are degree of achievement group evidenced evaluation of progress signed off by a or response to the towards the desired goals and were signed registered nurse when support and/or off by a registered nurse when the issues resolved. intervention, and were resolved. progress towards meeting the desired 90 days outcome.
and management of weight loss in three of six files reviewed. Maternity Five client were reviewed. All files evidenced that daily updates to postnatal care plan and labour/birth infant summary were not completed. (a-b) Ensure all documentation meets facility and legal requirements. Include dietary requirements to the postnatal care plan. 30 days Criterion 1.3.8.2 Evaluations are documented, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. PA Low Care staff document in progress notes on every shift. Care plan evaluations are conducted six monthly. Short-term care plans have been developed. Two of six short-term care plans from the sample group evidenced evaluation of progress towards the desired goals and were signed off by a registered nurse when the issues were resolved. Two of four short-term care plans reviewed did not document evaluation of progress towards the desired goal and two had not been signed off when resolved. Ensure short-term care plans are evaluated to monitor progress towards the desired goal and are signed off by a registered nurse when resolved. 90 days
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