Prospectus Checklist

Problem: 

1) Poor compliance, just 40% of the hospital inpatient nurses are using the hospital newly built-in standardized care plans.

2) The Joint Commission (JHACO) penalized the hospital during a recent visit to the hospital because only a small percentage of the admitted patient had a care plan upon admission based on their diagnosis or primary problem(s).

3) The hospital recently transitioned to a new and better electronic health record system (EHRs) and some nurses are stating that they haven’t received enough education on how to use the standardized care plans on the hospital new EHRs.

Below is the Joint Commission Standard for Care Plans

Joint Commission Standard

  • The      medical record contains the following clinical information:

– The reason(s) for admission for care, treatment, and services

– The patient’s initial diagnosis, diagnostic impression(s), or condition(s)

– Any findings of assessments and reassessments 

– Any allergies to food

– Any allergies to medications

– Any conclusions or impressions drawn from the patient’s medical history

and physical examination

– Any diagnoses or conditions established during the patient’s course of

care, treatment, and services (including complications and hospital acquired

infections). 

– Any consultation reports

– Any observations relevant to care, treatment, and services

– The patient’s response to care, treatment, and services

– Any emergency care, treatment, and services provided to the patient

before his or her arrival

– Any progress notes

– All orders

– Any medications ordered or prescribed

– Any medications administered, including the strength, dose, route, date

and time of administration

– Any access site for medication, administration devices used, and rate of

administration

– Any adverse drug reactions

– Treatment goals, plan of care, and revisions to the plan of care 

– Results of diagnostic and therapeutic tests and procedures

– Any medications dispensed or prescribed on discharge

– Discharge diagnosis

– Discharge plan and discharge planning

  • The hospital plans the patient’s care      based on needs identified by the patient assessment, reassessment, and      results. The written plan of care is based on patient goals and time      frames required to meet goals. Patient care plan is based on established goals where      staff evaluate the patient progress Patient’s care plan is revised with      goals based on patient’s needs

POPULATION: Inpatient Nurses

INTERVENTION: (Will an educational tool?) Best method on educating inpatient nurses on identifying appropriate patient’s diagnosis or primary problem upon admission to select individualized care plan and document on the interventions / progress toward patient goals each shift in Epic EHRs. 

COMPARISON: Regular Care plan

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