PLAN OF CARE (POC)

Requirements: All field users, case managers, and clinical administrators can post information and instructions and make changes to this form if they have a HHC Ultra user’s account and have access to these sections.

HHC made it easier for users to create the patient’s Plan of Care through pre-fills and look-ups available in the system. This form is located at the OASIS/Plan of Care section of the Patient Summary Page.

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Ongoing tasks for the POC are also shown as alerts along with other pending assignments at the Open Task section of the patient summary page.

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Upon clicking on the link, the user will be directed to the POC section wherein it is divided into different tabs according to the data set needed to be entered namely Diagnosis, Medication, Precautions, Limitations, Orders, Goals and Others. The first tab is the Diagnosis section of the POC.

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FILLING OUT THE POC

The first to be filled out is the diagnosis section. If the patient diagnosis were defined when the intake forms were filled up, it will be available on this page. If there were other diagnoses that are yet to be defined, the clinical manager can add it here. The pencil-and-paper icon enables users to edit the pre-defined information available.

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The auto-complete matches are available on this page, both in the text and code/numeric fields for users to use. Only by typing in the first few characters of the code or the text form will open the box where the selection is available. The entry could be selected by clicking on the appropriate information to be integrated into the system.

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The medication section also has its auto-complete functionality wherein the first few letters of the medicine will show a list of possible matches.

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Users filling-up this form can also have the medication classified by pharmaceutical arrangement. The user can select from the available drug type listing by putting in the supposed letter that will identify the type of category the drug belongs.

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Other than these, the prescription type can also be set on this page. The choices are New, Changed, Discontinued, On-hold and Old Medicine.

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The precautions section comes next. On this page are mostly spaces that clinical managers can fill up using the look-up functionality or the free text format.

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Checkboxes are available in the limitations section. Options are equipped with checkboxes and free text fields for answering.

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On the order section, users can access the Clinical Pathway and OASIS Pointer links. Notice that these come with generic pre-fills for diagnosis, visit-to-visit instructions and recommendations from previous ADLs/IADLs.

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Also, most of these tabs come has pre-fill icons adjacent to free text boxes for direct loading of the pre-made entries.

The goals section contains the goals for the patient’s care. You can set the goals templates on the POC Template found in the Admin Menu. Most of the tabs come with pre-filled information that users can use.

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Other prefill links include POC data from OASIS will show information coming from the OASIS supplemental items filled out by the care staff doing the initial evaluation and the Intervention from Admission Order, which was given as directive of the primary physician.

Other section is for additional documentation. Rehabilitation Potential, Discharge Plans and Other Notes documentation templates can also be set on the POC template from the Admin Menu. The user also has an option to copy documentation from the OASIS and Admission Order.

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The FTF section is for the documentation of the face to face visit of the patient.

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Upon the creation of the Plan of Care of the patient, the Clinical Manager could refer to the previous patient records for vital sign parameters or could solicit the information from the physician. The slots for filling this out are located on the last tab of the POC/485 page.

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To put in values to the range boxes, one should first select the type of vital statistic category from the dropdown box, type in the numeric information on the Minimum and Maximum value fields and a reminder on the text box to the right of the page.

To add the information to the Plan of Care, the user should click on the icon that looks like a green cross at the end of the row. Entries can also be deleted by clicking on the “X” icon, also at the end of the row. It is also recommended to hit on the Save button when the information is completed. These steps will ensure the activation of the Vital Signs Alert section.

FINALIZING THE POC

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The toolbar on top of the different segments could be used to complete the patient’s Plan of Care. The “Save” button is the first button found on this row. This is used to have the encoded or pre-filled data integrated into the POC form.

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Bear in mind, that even if this section has an auto-save feature, it is crucial to still click on this button, especially at the end of the process to prevent omission of previously set data.

Before having the Sent and Received To Physician date fields available on the toolbar, one would have to flag the form for review by Case Managers.

The POC cannot be marked as reviewed if OASIS has not been finalized or locked

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When the user clicks on the verification prompt, the button changes to “Send POC”. Agency personnel could click this to put in the tracking date for this document.

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When the action for delivery has been marked as confirmed, the icon again changes to Receive from Physician and an additional button appears next to it enabling the Reset Sent Date for the document. Clicking on the “Electronically Sign / Receive POC” option would open a pop-up to let users define a date or enter the user PIN. This will complete the e-Signature task for the physician. Choosing the button next to it will revert the option that the Flagged for Review is available.

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The Lock Document for Exclusive Use is offered for clinicians assigned to do the completion of the POC to have it entirely to himself to fill-up the data. This is usually enabled to disable other clinicians from adding additional information that is not vital to the patient's care plan.

Also, the care staff assigned to have this completed could refer to other care plans by clicking on the Other PT with Similar Diagnosis functionality. This is available to supervising clinicians and completing staff to refer to other patients’ POC especially those having the same diagnoses. To view the POC, click on the available choices.

The print button that creates standard formatted POCs at the touch of a button.

Other than this, the completed POC can be viewed or printed at the Patient Chart View Beta along with the rest of the other documents.

Users can also use the “Upload File” function if they wish to attach any documentation to the Plan of Care. Upon clicking on this button, an uploader window will be available so that those filling out this form can fasten additional data with the care plan.

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Version Control #: DSL2019-2.2

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