Once a diagnosis-based care plan is created for a patient, it will appear in each visit for that patient if the visiting staff member has a discipline care plan.The diagnosis-based care plan on the main menu appears with the discipline letters, such as SN for Skilled Nursing. Click on that menu item in the assessment to pull up the care plan and begin documenting within your visit. Note that even though the care plan appears first on the menu list in your visit, you don't have to document it first: you can complete other required screens and then come back to the care plan if you prefer.
1. In the Interventions tab, all of the interventions on the plan are available. You can click the All Interventions Completed button to mark them all as checked at once, or you can check them off one-by-one. You may also type comments under any where you'd like to comment.
2. In the Goals tab, you can indicate the progress the patient has achieved as of this visit toward each goal. You can also type a comment. The Use Previous Values button at the top will pull the percentages from the previous visit so you can use them as a guideline toward assessing where the patient is now in comparison.
3. The Notes tab allows you to document discharge plan notes and plan for next visit.
4. Patient Communication allows you to document various aspects of patient communication specified by Conditions of Participation, such as instructions.
5. If you need to change interventions or goals during a visit, keep in mind that this will require a change order, and you can make the changes by clicking the Edit Care Plan button in the upper right. Instructions for using this part of the system are included in the instructions on adding a new care plan.