Plan of Care Management

Overview

The Plan of Care (POC) outlines the goals, interventions, and expected outcomes for a patient's episode of care. It's a living document that guides the care team's approach and must be regularly reviewed and updated.

Accessing Plan of Care

From Patient Chart

1. Navigate to Patient Chart: Select patient from patient list
2. Access Plan of Care:
   • Navigate to patient's plan of care section
   • Or access via patient navigation menu
3. View Plan: Current plan of care displayed

Direct Navigation

• Navigate to /p/[referralId]/plan-of-care in your browser
• Access from patient chart navigation
• Use patient menu options

Plan of Care Structure

Components

A Plan of Care includes:

• Goals: Specific, measurable patient goals
• Interventions: Actions to achieve goals
• Expected Outcomes: Anticipated results
• Review Dates: Scheduled review periods
• Progress Notes: Documentation of progress

Goal Categories

Goals are typically organized by category:

• Functional Goals: Mobility, ADLs, independence
• Clinical Goals: Health status, symptom management
• Educational Goals: Patient/family education
• Safety Goals: Fall prevention, medication safety
• Psychosocial Goals: Emotional well-being, support

Creating a Plan of Care

New Plan Creation

1. Navigate to Patient Chart: Select patient
2. Access Plan of Care: Go to plan of care section
3. Create New Plan: Click "Create Plan of Care" or similar
4. Set Episode: Associate with current episode
5. Add Goals: Define patient goals
6. Save Plan: Plan created and active

AI-Generated Plans

Some organizations have AI assistance for plan generation:

1. Access Generator: Click "Generate Plan of Care" button
2. AI Analysis: System analyzes patient information
3. Review Suggestions: AI provides goal suggestions
4. Customize: Edit and refine AI suggestions
5. Save: Accept customized plan

Manual Plan Creation

1. Start New Plan: Click "New Plan" or similar
2. Add Goals: Enter goals manually
3. Set Interventions: Define interventions for each goal
4. Set Outcomes: Specify expected outcomes
5. Set Review Dates: Schedule review periods
6. Save Plan: Plan created and active

Managing Goals

Adding Goals

1. Plan Editor: Open plan editor interface
2. Add Goal: Click "Add Goal" or "+" button
3. Enter Goal: Type specific, measurable goal
4. Set Category: Assign goal category (if applicable)
5. Set Target Date: Assign target achievement date
6. Save Goal: Goal added to plan

Editing Goals

• Select Goal: Click on goal to edit
• Modify Text: Edit goal description
• Update Dates: Change target dates
• Change Category: Reassign category
• Save Changes: Updates saved automatically

Deleting Goals

1. Select Goal: Click on goal
2. Delete Option: Access delete option (via menu or button)
3. Confirm: Confirm deletion
4. Update Plan: Goal removed from plan

Goal Status

Goals have different statuses:

• Active: Current goal in progress
• Achieved: Goal successfully met
• Discontinued: Goal no longer relevant
• On Hold: Temporarily paused

Updating Plans

Regular Reviews

Plans of care should be reviewed regularly:

• Initial Review: After plan creation
• Periodic Reviews: At scheduled intervals
• Change Reviews: When patient condition changes
• Recertification: During episode recertification

Making Updates

1. Open Plan: Access current plan
2. Edit Mode: Click "Edit" to modify plan
3. Update Goals: Modify existing goals
4. Add New Goals: Include additional goals as needed
5. Update Status: Change goal status
6. Save Changes: Updates saved

Version History

• Previous Versions: Access previous plan versions (where available)
• Change Tracking: View what changed and when
• Review History: See review dates and updates
• Audit Trail: Complete history maintained

Plan Review Process

Review Workflow

1. Schedule Review: Set review date when creating/updating plan
2. Review Reminder: System reminds when review due
3. Conduct Review: Evaluate patient progress
4. Update Plan: Modify goals and interventions as needed
5. Document Review: Record review findings
6. Set Next Review: Schedule next review date

Review Documentation

• Progress Notes: Document patient progress
• Goal Achievement: Note which goals achieved
• Intervention Effectiveness: Assess intervention success
• Plan Modifications: Document changes made
• Next Steps: Plan for upcoming period

Best Practices

Goal Setting

• Specific Goals: Make goals specific and measurable
• Realistic Targets: Set achievable goals
• Patient-Centered: Include patient priorities
• Time-Bound: Assign target dates
• Review Regularly: Update goals as progress occurs

Plan Management

• Keep Current: Update plans regularly
• Document Changes: Record all modifications
• Team Communication: Share updates with care team
• Patient Involvement: Include patient in goal setting
• Outcome Focused: Focus on meaningful outcomes

Documentation

• Complete Documentation: Document all aspects of plan
• Clear Language: Use clear, professional language
• Timely Updates: Update plans promptly
• Review Tracking: Maintain review schedule
• Continuity: Ensure continuity between episodes

Related Topics

• Patient Charts & Navigation - Navigating patient charts
• Patient Tasks & Episodes - Understanding episodes
• Clinical Documentation - Completing documentation