PLAN OF CARE
revised 1/21/2015
Data Definition Tool
Indicators
5 Correct or Best Path from E-docs chosen.
Standard
Location
Yes
NO
RC.02.01.01
StarPanel, Actions, Edocs Pathway documented, if
Path, displays in OPC
applicable.
Incorrect pathway chosen
6 Pathway selected from: E-Docs and saved to Star
PC.02.01.01;
Panel within 8 hours of admission, where applicable. RC.02.01.01
StarPanel, Actions, Edocs Pathway saved to SP
Path, displays in OPC
within 8 hours of
admission, if applicable.
Pathway selected > 8 hours
from admission.
7 Phase of pathway is documented in HED when the PC.02.01.01;
Pathway is assigned and with any changes. If
RC.02.01.01
neither Pathway or Phase changes it is not
necessary to redocument this information until there
is a change.
8 Priority Problems (max. 4 - unless restrained, then PC.02.01.01;
5) identified within 8 hours of admission and
reassessed for continued appropriateness each
shift.
1)HED POC tab, 2) paper
if documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
1)HED POC tab, 2) paper
if documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
9 *Expected Outcome identified for each Priority
Problem. (Improve, Stabilize, Support Decline)
PC.01.03.01;
RC.02.01.01
10 *Short Term Goal documented for each Priority
PC.02.01.01
Problem during the first 4 hours of each shift. (Note:
Not all problems priority each shift. Activity may be a
Priority Problem on days and Sleep Disturbance on
nights.)
11 Goal Status documented for each Priority Problem PC.01.03.01;
during the last 4 hours of each shift.
RC.02.01.01
If pathway is assigned or Pathway assigned or changed
changes - document in
and there is no documentation.
HED. If not, NA.
Patient has been
admitted 8 hours and
Priority Problems(PP)
are documented or
reassessment of PP
documented.
1)HED POC tab, 2) paper Expected Outcome is
if documented during HED documented for each
downtime, 3) StarPanel
PP.
HED pdf if >48h since
discharge
1)HED POC tab, 2) paper During first 4 hours of
if documented during HED shift a short term goal is
downtime, 3) StarPanel
documented on each PP.
HED pdf if >48h since
discharge
1)HED POC tab, 2) paper Documentation during
if documented during HED the last 4 hours of shift of
downtime, 3) StarPanel
goal status.
HED pdf if >48h since
discharge
No documentation of priority
problems
Expected Outcome for one or
more PP is not documented.
>4 hours into shift before
documentation of short term
goal or there is no
documentation of short term
goal for a PP.
No documentation during the
last 4 hours of shift of goal
status. Or no documentation at
all.
12 Nursing Summary and Plan Priorities are
documented on each patient within 4 hours of the
end of the shift.
RC.02.01.01
13 Priority Problems are evaluated each shift for
PC.01.03.01;
ongoing appropriateness and are discontinued when RC.02.01.01
resolved, if they cease to be priorities, or at
discharge.
14 When Priority Problems are ended, Actual
PC.01.03.01;
Outcomes and whether or not the Problem is
RC.02.01.01
resolved are documented. At discharge, if a Priority
Problem is not resolved, document the plan for
continued follow-up for that problem after discharge
1)HED POC tab, 2) paper
if documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
1)HED POC tab, 2) paper
if documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
1)HED POC tab, 2) paper
if documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
Nursing Summary and
Plan Priorities
documented in last 4
hours of shift.
No documentation of Nursing
Summary and Plan Priorities in
last 4 hours of shift.
Evaluation or resolved is Either evaluation of PP or
documented on each PP. resolved is not documented on
one or more PP.
Actual Outcome or
resolved or follow-up
plan is documented on
all PP.
Actual Outcome or resolved or
follow-up plan is not
documented on one or more
PP.