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Select Care Plan from the Patient Navigation Menu.  All existing Care Plan Problems will display.

At this point, you can either View or Edit  the Care Plan Problem by clicking on the name of the problem or selecting the appropriate BLUE BOX to the right of the Care Plan Problem Title.

NOTE:  The Care Plan section of the program is INDIVIDUALIZED.  Goals are identified for WHO (Patient, PCG, etc.).  Goals are also measurable, by identifying when expected outcome will occur or goal will be met.   The Care Plan section of the program is INTERDISCIPLINARY. That is, the goals and interventions contain physical, emotional, psychosocial, and spiritual options and are meant to be used by all disciplines; therefore, they are always editable unless the Care Plan Problem is “resolved”.

EXAMPLE:  Nurse makes an initial visit to patient’s home and determines that the patient has Physical pain.  Nurse adds a care plan problem ‘Alteration in Physical Comfort—Pain’.  Social Worker makes her initial visit and determines that the patient has emotional issues relating to pain.  SW moves to the ‘Care Plan’ section of the chart and chooses the Pain Care plan by selecting ‘edit’.  SW adds her goals and interventions to the Pain Care Plan problem.  The program tracks each entry by worker and date.

Once a problem has been resolved by the Team, the Care Plan Problem can be ‘resolved’ by selecting the blue ‘resolve’ button to the right of the Care Plan Problem title or by selecting resolve from the Patient Task Bar.  Once resolved, the Care Plan Problem can no longer be edited.  Do not resolve a Care Plan Problem unless the patient no longer has that problem.

If when viewing the problem, you determine that changes need to be made, select the blue Edit   button located in the right of the Care Plan Problem title or by selecting Edit from the Patient Task Bar.

The Care Plan Problem with previously answered questions will appear.  The Care Plan Problem may now be edited.  Additional boxes may be checked to identify the problem manifested differently, or that additional goals and/or interventions are required.

Boxes can be unchecked or the DC box can be checked to identify the cause has been resolved, goal is met or not appropriate, or interventions have been completed or no longer effective.

When finished with updating the Care Plan Problem, select Preview from the Patient Task Bar.  The items that were DC’ed will display as DC’ed – with a line through the text as this denotes that the previous response is no longer applicable.  

Choose ‘Add Problem’ from the Patient Task Bar add a new care plan problem to the chart.

The list of Care Plan Problem choices will display.

Note: the list you view is determined by the organization.

If the patient has a medication profile established when adding or editing a problem, a list of medications will display at the bottom of each problem and can be added to the problem.

If a Care Plan Problem was selected in error, choose Undo from the Patient Task Bar.  The Care Plan has to be in ‘edit’ format in order to ‘undo’.  

Resolving a Care Plan problem denotes that the patient no longer has that problem.  For example, the patient is receiving CNA services and the nurse has completed a CNA Assignment Care Plan.  The patient’s daughter decides to provide the bathing services; the CNA Assignment Care Plan can be ‘resolved’.  ‘Resolved’ care plan problems do NOT display on the overview page.

Preview the problems before moving onto another problem or section.

Another feature within the Care Plan section is the ‘Display’ feature.  By selecting the blue bar to the right side of the screen that reads Change Details Range, the user is able to view all changes with dates and persons documenting changes to care plan.  This will be viewable in blue. 

Select Change Details Range and choose the dates ‘From’ – ‘To’.

Select Display. 

Note:  the ‘Details Display’ is configurable by your site to include ‘visit time’ or ‘actual time’ along with the user’s name.

ADDING NOTES TO CARE PLAN PROBLEMS:

A user can easily make notations as to the progress of the patient toward goals in the TAKE GENERAL NOTES pane (on the right-hand side of the screen).  To do this, click on the down arrow beside the words ‘Take General Notes.’ Scroll down to the Care Plan Problems listed IN WHITE (under Care Plan Take Notes).  Select the problem to add a note to (progress toward goals, evaluation of interventions, patient’s response to care).  Type your note in the large box below the Care Plan Problem selected.

The Take General Notes pane is available from most screens within the patient’s chart.  Notations can be made while the user is working on forms, care plans or orders. 

The notation added in the right pane, mapped to the appropriate Care Plan Problem will display at the bottom of the care plan in gold.  Date/time and worker adding note will display also.