PATIENT CARE PLAN

The patient's care plan can be found and edited through the following:

Physician Telephone Order (PTO) - located after the "Type of Order" section or "Change Visit Frequency" panel.
- Admission Order
- Resumption Order
- Recertification Order
- Care Plan Order
- Other Follow-up (SCIC)
Outcome and Assessment Information Set (OASIS)
Plan of Care (POC)
Telephone Communication Note (TCN)

CARE PLAN ON THE PHYSICIAN TELEPHONE ORDER (PTO)

The user can make updates to the Care Plan by creating a Physician Telephone Order.

Note: Both the OASIS and POC need to be locked for the Update Care Plan Order Type to show.

Create a new PTO and fill up the necessary details:

Physician for the Order
Carestaff for the Order
Order Date

After this, select the Care Plan Order under the Type of Order dropdown list.

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Once an order is selected, the Care Plan section will show.

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The user can then click on the "Add New Problem" to add.

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On the Add New Problem box, select a Body System from the drop-down options and click search to show all the Problems listed under that Body System.

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Select all applicable Problems from the list by ticking the checkbox beside it. Then click Add when done.

Note: The same problem description can be added as long as the body system is different.

Once added, the item/s will now be visible in the Care Plan. The Problem section is collapsible. Just click the arrow button on the right-hand side to collapse or expand it.

Expanding the section will show several other fields, including the following:

Description of the Problem
The Body System to where the Problem belongs
The document Source
The Problem Status, which the user can set to Not Resolved, In Progress, or Resolved
An option for the user to indicate if the said Problem is Related to HHC Diagnosis or not
The Severity of Care Problem, which the user can edit and update

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Sync Care Plan From Oasis - This button can be used if you have already entered the Care Plan in the OASIS.

Note: This will reset the unsaved changes and populate data from OASIS. Source type from OASIS will then be changed to PTO. Once unsaved changes are deleted, it will only exclude the deleted data and not affect other related data.

Click on the Add Care Goal button located inside the Problem panel to add a Care Goal.

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On the Add New Care Goal box, click search to show all the goals listed under that Problem.

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Select all applicable Care Goals from the list by ticking the checkbox beside it. Then click Add when done.

Note: The same goal description can be added as long as the problem is different.

After adding, the Care Goal/s will appear on the list. The user can then fill up the Target Date (required field), Care Goal, Source, Comment, Goal Set For, and Resolution Date fields for each care goal added.

The user can click the arrow located on the left-hand side to collapse or expand the section.

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Expand the Care Goal section by clicking the arrow located on the grid's left-hand side to add Intervention/s for a Care Goal. An Add Int... button will show. Select it to open a popup and add the corresponding interventions.

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On the Add New Care Intervention box, click search to show all the Interventions related to the Problem and Care Goal.

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Select all applicable Interventions from the list by ticking the checkbox beside it. Then click Add when done.

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After adding, the Intervention/s will appear on the list with the following fields:

The Initiated field will let the user assign the carestaff that initiated the intervention
The Intervention field will allow the user to edit/update the intervention details
The Source field will show the user the document source of the intervention
The Goal Outcome/Comment field is where the user can indicate if the Goal was met and add other necessary information
The Resolved field is where the user can indicate who was the carestaff who was able to Resolve the intervention

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To assign/update the carestaff, click the no assigned carestaff or carestaff name.

Note: The only visible carestaffs are those carestaffs that the user assigned to the patient under the Admission page.

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Click on the Comments(#) link under the Goal Outcome field and a popup box will show. This will let the user add an Intervention Comment.

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Notes:

Newly added comments or comments that are not yet saved will have edit and delete functionality.

Once a comment is saved, the user can no longer edit or delete the comments.

Saved comments will have addendum functionality, and once added, they will have edit and delete functionality.

If Intervention already exists, Intervention comments will be automatically saved after closing the comment popup.

Once the identified problems have been added and the user is done with the PTO, click the SAVE button.

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The Update Care Plan button updates the Care Plan after saving the Physician Telephone Order.

Note: There is no need to save the PTO once you click on the Update Care Plan button.

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Updating the Care Plan if OASIS and POC are locked:

Go to the Orders section, select the Care Plan Order as the Type of Order, and repeat the same process as adding a care plan problem.

Care Plan Information and Alteration Flow:

Data from the Physician Telephone Orders will be available in 3 other sections.

All changes coming from the PTO page will appear in the OASIS, POC, and CarePlan Profile. If PTO is locked, only OASIS and POC will be available for changes.

CARE PLAN ON THE OASIS

The Care Plan Button is located at the bottom part of the page. It is in line with the Save and Validate buttons. Clicking the button will show a pop-up panel that shows the whole Care Plan.

All changes coming from the Oasis page will reflect in POC and CarePlan Profile. If the Oasis is locked, you can only modify the POC.

Note: To modify or update the Care Plan in the OASIS, make sure that the OASIS is in progress.

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Make all the necessary changes and once all vital information is filled in, click on the Update Care Plan button located on the lower right-hand side of the screen to save all the changes.

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CARE PLAN ON THE PLAN OF CARE (POC)

The Care Plan is available on all POC pages. The Care Plan on the POC is located under the Goals tab.

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Add New Problem - This is the same process as the PTO/OASIS. It will let the user add a new Problem under a selected Body System. However, the Source will be POC instead of the PTO/OASIS this time.
Updated CarePlan - This will get the latest changes to the care plan without refreshing the whole page.
1. - Note: Any changes in the POC Care Plan will not affect the PTO and Oasis Care Plan once updated.

To add a new entry, the user needs to:

Click the Add New Care Problem button
Select a Body System
Select a Problem
Then click Add

Then the user can add Care Goals and Interventions afterward. After all the changes are made, the user can now save the PTO, and the changes will then reflect in the Care Profile of the Patient.

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Flagging Care Plan Goals as Resolved:

If and when the Plan of Care is already locked and electronically signed, the way to flag it as resolved is by creating a Care Plan Order or Telephone Communication Note.

Use a Care Plan Order if a physician's signature is needed. The process is the same as creating an order.

CARE PLAN ON THE COMMUNICATION NOTE (TCN)

In the patient Summary Page, go to ‘’Comm. Notes’’ tab and click New Communication Note and check the Resolve CarePlan checkbox.

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This allows the user to update the following items:

Problem Status - This indicates if the Care Problem Status is In Progress, Not Resolved or Resolved
Resolution Date - This specifies the resolution Date of the specific Care Goal

Initiated By and Initiated Date: The user can see the assigned carestaff and start date for the particular Intervention for the specific Care Goal of the Problem.

Note: In the carestaff dropdown, only assigned carestaff will be available.

Resolved by and Resolved Date: The user can see the assigned carestaff and start date for the particular Intervention.

Note: The Goal Outcome dropdown menu is grayed out on this section.

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Comment(s) - This is where the user can see/add comment/s for the specific Intervention.
Addendum Comment - This is where the user can add an addendum for added Comments.

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PATIENT CARE PLAN PROFILE

The user can go to the CarePlan Profile to view the Patient's Care Plan for a specific episode. All changes coming from different pages will be viewed, filtered, printed on this page. However, only the last modifications are available for viewing.

To view, users must go to the Patient Summary and click the CarePlan Profile tab.

Note: CarePlan Profile can also be viewed on Patient Chart View.

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Search - This button is located on the upper right-hand side of the screen, allowing the user to display and filter the data.
- 1. Filters are composed of the following fields:
    - Initiated Date - Intervention initiated date range
    - Initiated By - Intervention initiated by carestaff
    - Resolved Date - Intervention resolved date range
    - Resolved By - Intervention resolved by carestaff
    - Goal Outcome - Intervention goal outcome level
    - Severity of Care Problem - Problem Severity of Care Problem
    - Target Date - Care goals Target Date range
Clear Filter - This button allows the user to clear the filters recently used.
Print Care Plan - This allows the user to print the Episode’s Care Plan information.

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Version Control #: DSLC2022-1.0

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