Our standard joint care plan covers 7 areas. I'll just list you out what it looks like
Pain Management - Pt will verbalize tolerable level or pain on oral pain meds and be discharged on these medications to home/rehab
Mobility - Pt will demonstrate proper ambulation safely w/ assistive device as needed prior to discharge to home/rehab.
Tissue Perfusion - Pt will demonstrate adequate tissue perfusions as per CMN checks upon discharge to home/rehab.
Infection Control - Pt will verbalize signs and symptoms of infection and 2 ways to prevent infection prior to discharge.
Management of Pt Safety - Pt will be free of falls during hospitalization.
Dischange Planning - Pt will verbalize understanding of follow-up plan upon discharge to home/rehab.
Potential Alteration Anxiety r/t Hospitalization - The pt will verbalize 2 ways to reduce feeling of anxiety during hospitalization.
There is then blank space to enter any futher specific goals for the pt related to nutrition or another condition/issue they may be having.
That's the cover page. Inside there is a page to prioritize the goals daily, a place for all members of the team (case management, PT, OT, dietary, pastoral care, etc.) to initial when they see the pt and enter their name and contact info. The next page is to assess barriers to learning and motivation to learn and the pt's anticipated learning needs (self-care activities, safe and effective use of medical equipment, pain risks assessments and treatment, safe and effective use of medication, potential food-drug interaction, and determining need for further treatment) and a place to document any teaching materials used. The last page is to document teaching about the surgery, any meds, pain management, counseling, treatments, procedures and the pt's response. This is basically our hospitals standard, blank care plan filled out for our ortho pts. It's focused toward hip/knee, but we do use it for other surgeries. We have a seperate POC for spines. And if it helps, we have our disease specific cert in hip/knee.