Care Planning

Here is my rant, first.

Hospice care and Home Care planning should be really easy. More nurses need to be involved in the development of EMRs so that the end products are SAVING us time while IMPROVING our documentation. The technology is there to make EMRs effective and efficient for the user. Nurses spend more time with the EMR than any other one clinical discipline, we should be central to the development of ANY documentation system. End of rant.

I recommend to establish the long term hospice goals; overall comfort expectations, maintenance of skin, environment for death, end of life wishes and rituals, etc. Beyond those the case manager needs to narrow the field of view. Where are the "alterations" or "disturbances", the things that are different/troubling to the patient? The "alteration in elimination" perhaps or "sleep disturbance"? The things that are causing alterations to the POC.

So if the case manager must document a change in the medication treatment plan, or the nursing treatment plan. Or if the MSW, or Chaplain, or Physician is recommending change to the existing POC (especially in the IDT) there should be a problem on the list with short term goals that advance with each IDT toward long term goals. Conceivably, problems addressed in the POC will have times when they are stable and well managed 'duration of care' sort of durations and times when they are acute issues requiring increased intervention and use of resources with much shorter duration for goals. I mean, we want them to poop before the 'duration of care' part is used up, right? We even really want them to poop before the next RN visit, most likely. There is the short term duration that you are looking for.

A simple way to beat the "duration of care" issue is to have few items on the POC with goals that extend beyond the date of the next IDT (environment of death, DNR, etc). That requires that each IDT represents the group approval of the POC as it will be utilized going forward from that meeting. (This is part of the philosophy of working to make the IDT a planning/problem solving opportunity rather than a historical reflection on past care status). Addressing the POC so specifically for each patient at each IDT creates more work for the RN case manager, but makes the POC more specifically reflective of the patient. That is what JC is looking for, evidence that your POC is not cookie cutter, but is reflective of and responsive to changes in the patients "status quo".

Those are, pardon my french, but very crappy and vague goals. Goals need to be measurable and time specific.

"Pain will be managed for duration of care"

What is the current pain level, how will you know it needs to be managed, how long is the duration of care?

A better goal is 'Patient will maintain a pain level of two, on a scale of zero to ten (where zero is no pain and ten is the worst they've ever experienced), for the duration of the shift'.

OR

'Patient will not verbally express the need for additional pain medication prior to the next scheduled dose at 1230H'

"Skin will remain intact for the duration of care"

What about excoriation, is a pressure ulcer already visible, but not open? Again what is the time period you are qualifying -duration of care is too vague, as is the statement skin will remain intact.

A better goal is something like 'The stage I pressure ulcer located on the coccyx will not evidence any progression to that of a stage II by the time of the next wound care consult scheduled for May 7th 2014 on day shift.'

I think that is an excellent idea. We will ammend each careplan at IDT for achievable goals by next IDT.

I thought your answer was very informative. Pardon my ignorance, but what is an EMR?

Electronic Medical Record