PLAN OF CARE
Rev 12-17-15
Data Definition Tool
1
2
3
4
Indicators
RN assigned
Medical Record #
Date of Documentation
Priority Problems (maximum 4 unless restrained, then 5) identified
within 8 hours of admission.
Standard
PC.02.01.01;
5 Goals documented for each Priority
Problem during the first 4 hours of
each shift or admission to the unit.
PC.02.01.01
6 Identified priority problem outcomes
are updated/documented throughout
the duration of the shift or within the
last 4 hours of each shift.
PC.01.03.01;
RC.02.01.01
7 If a Priority Problem is not resolved at
discharge, follow-up needs/plans are
documented.
PC.01.03.01;
RC.02.01.01
Location
Yes
1)HED Plan tab, priority
problems highlighted in
red 2) paper if
documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
1)HED Plan tab , 2) paper
if documented during HED
downtime, 3) StarPanel
HED pdf if >48h since
discharge
1)HED Assessment tab,
2)HED Vital Signs and
I&Os tab, 3)HED Plan tab,
4) paper if documented
during HED downtime, 5)
StarPanel HED pdf if >48h
since discharge
Patient has been admitted 8 hours
and Priority Problems are identified.
During first 4 hours of each shift or
admission to the unit, goals are
documented on each Priority
Problem.
Identified priority problem outcomes
are updated/documented throughout
the duration of the shift as part of the
RN assessmet or within the last 4
hours of each shift under Response
to Care/Recommendations.
1) HED Plan tab under
Discharge Problems needing followPlan of Care Discharge
up are documented on all unresolved
Problems Needing Follow- Priority Problems.
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