PLEASE COMPLETE ALL HIGHLIGHTED EDITS ASAP SO I CAN PUSH POC.
PLEASE REVIEW THINGS
IN RED TO SEE WHAT WAS EDITED FOR YOU FOR FUTURE SOCS
ATTACED IS THE LIST OF CARE PLANS THAT ARE THE MINIMUM FOR EVERY ADMISSION—NURSING
HIGHLIGHTED IN YELLOW; AS WELL AS CARE PLAN LIST FOR FUTURE REFERENCE
PROBLEM: MEDICATION MANAGEMENT (MED TEACHING)
GOAL: PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF MEDICATION
REGIMEN, SIDE EFFECTS TO REPORT AND PROVIDE MEDICATION AS ORDERED BY END OF CERT.
INTERVENTION: HOSPICE NURSE TO INSTRUCT PATIENT/CAREGIVER ON NEW AND CHANGED
MEDICATIONS INCLUDING PURPOSE, LENGTH OF THERAPEUTIC ONSET, SCHEDULE, IMPORTANCE OF
COMPLIANCE, AND SIDE EFFECTS TO REPORT.
PROBLEM: RESPIRATORY (OXYGEN SAFETY)
GOAL: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING OF PROPER USE OF OXYGEN,
INCLUDING FLOW RATE, EQUIPMENT CARE, MAINTENANCE, STORAGE AND SAFETY BY END OF
CERT.
INTERVENTION: HOSPICE NURSE TO INSTRUCT PATIENT/CAREGIVER ON PROPER USE OF OXYGEN,
INCLUDING FLOW RATE, EQUIPMENT CARE, MAINTENANCE, STORAGE AND SAFETY.
PROBLEM: RESPIRATORY (PULSE OX)
GOAL: PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF MEASURES TO
MANAGE DYSPNEA BY END OF CERT
INTERVENTION: HOSPICE NURSE TO ASSESS PATIENT'S PULSE OXIMETRY READINGS PRN AND
INSTRUCT PATIENT/CAREGIVER ON MEASURES TO ASSIST IN MANAGING DYSPNEA.
PROBLEM: SAFETY (FALL PREVENTION)
GOAL: PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE EFFECTIVE HOME SAFETY AND FALL
PREVENTION MEASURES/STRATEGIES AS EVIDENCED BY PATIENT WILL REMAIN FREE FROM INJURY
THROUGHOUT THE EPISODE.
INTERVENTION: HOSPICE NURSE TO PERFORM HOME SAFETY AND FALL ASSESSMENT AND PROVIDE
INSTRUCTION TO PATIENT/CAREGIVER ON IMPLEMENTATION OF HOME SAFETY MEASURES AND FALL
PREVENTION STRATEGIES.
PROBLEM: PAIN/COMFORT
GOAL: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING TO REPORT CHANGES IN PAIN
LEVEL THAT EXCEEDS PATIENT COMFORT LEVEL/PAIN GOAL TO HOSPICE NURSE BY END OF CERT
INTERVENTION: HOSPICE NURSE TO ASSESS PATIENT'S PAIN LEVEL AND INSTRUCT
PATIENT/CAREGIVER TO NOTIFY HOSPICE NURSE OF PAIN THAT EXCEEDS PATIENT'S COMFORT
LEVEL/GOAL AND/OR INEFFECTIVE PAIN MANAGEMENT.
PROBLEM: DISCIPLINES (CHAPLAIN)
GOAL: A CHAPLAIN PLAN OF CARE WILL BE ESTABLISHED THAT MEETS THE
PATIENT/CAREGIVER'S NEEDS.
INTERVENTION: CHAPLAIN TO EVALUATE PATIENT/CAREGIVER AND DEVELOP PLAN OF CARE.
PROBLEM: DISCIPLINES (MSW)
GOAL: A MEDICAL SOCIAL WORKER PLAN OF CARE WILL BE ESTABLISHED THAT MEETS THE
PATIENT/CAREGIVER'S NEEDS.
INTERVENTION: MSW TO EVALUATE PATIENT/CAREGIVER AND DEVELOP PLAN OF CARE.
PROBLEM: RESPIRATORY
GOAL: PATIENT/CAREGIVER WILL VERBALIZE S/S OF ASPIRATION AND DEMONSTRATE METHODS TO
MANAGE/PREVENT BY END OF CERT
INTERVENTION: HOSPICE NURSE TO INSTRUCT PATIENT/CAREGIVER ON SYMPTOMS OF ASPIRATION
AND METHODS TO MANAGE/PREVENT
PROBLEM: SPECIALTY PROGRAMS
GOAL: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING OF HOSPICE PHILOSOPHY AS A
RESULT OF PARTICIPATION IN CODE ANGEL SPECIALTY PROGRAM BY END OF CERT
INTERVENTION: HOSPICE NURSE TO INSTRUCT PATIENT/CAREGIVER ON HOSPICE PHILOSOPHY AND
WHEN TO CONTACT HOSPICE AGENCY UTILIZING THE CODE ANGEL SPECIALTY PROGRAM.
GOAL UPDATED TO BE MEASURABLE:
GOAL: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING OF DISEASE PROCESS INCLUDING
PROGNOSIS, SYMPTOMS, TREATMENTS, COMPLICATIONS, AND WHAT TO REPORT TO HOSPICE
NURSE BY END OF CERT
GOAL: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING OF PSYCHOLOGICAL EFFECTS OF
BOWEL INCONTINENCE AND MEASURES TO IMPROVE/MAINTAIN DIGNITY BY END OF CERT
GOAL: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING OF DEMENTIA DISEASE PROCESS BY
END OF CERT
HHA POC—PLEASE INITIATE AS THE HHA CANNOT COMPLETE VISITS UNTIL THIS IS DONE
MEDICATION EDITS:
PLEASE ADD OXYGEN TO THE MED PROFILE-ADDED BY CTM
IF ORDERED IT MUST BE ON THE MAR
MEDICATION FINANCIAL RESPONSIBILITY EDITS: FYI
ANY MEDICATION NOT RELATED TO DX WILL BE PART D TYPICALLY
ANY OTC MEDICATON/SUPPLEMENT WITH BE PATIENT
VA PAY WILL BE OTHER
FINANCIAL RESPONSIBILITY REASON THAT IS UNRELATED TO HOSPICE DX MUST STATE:
"UNRELATED TO HOSPICE DX OF ES RENAL DISEASE; RELATED TO CHRONIC CONDITION OF
DEMENTIA"—WE HAVE TO STATE WHY WE ARE NOT PAYING FOR THE MED.
CALENDAR EDITS:
ADMISSION NURSE IS RESPONSIBLE FOR ADDING THE INITIAL CHAPLAIN/SW VISITS AND HHA
VISITS
RN02H ADDED BY CTM
RN11 ADDED BY CTM
CH01 ADDED BY CTM
MS01 ADDED BY CTM
HS11 ADDED BY CTM
WEEKLY COMP VISITS ADDED---BY QA
SAFETY/FUNCTION EDITS:
OXYGEN PRECAUTIONS—ADDED BY QA
SUPPLY EDITS:
OXYGEN AND SUPPLIES---ADDED BY QA