Policy Manual sample

MDT Home Health Care Agency, Inc. 168 CARE PLANNING PURPOSE: To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes. POLICY: • The Patient plan of care is developed and documented by the Registered Nurse or Physical Therapist if a Physical Therapy-only admission, in coordination with the Physician, patient/family/ significant other. • The plan of care is communicated to the Case Manager/Clinical Supervisor and other members of the healthcare team. • When a patient is receiving more than one service, each discipline develops a plan of care. PROCEDURE: • Each discipline, i.e., nursing, therapies, social work, including contracted services, develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/admission visit. • The Case Manager/Clinical Supervisor receives a verbal summary of the plan of care the day of the initial/assessment visit. • The proposal plan of care is submitted to the Agency office within 72 hours of the initial visit. A copy of the plan of care may remains in the patient’s home. • The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient’s needs and clinical status, and promotes positive outcomes and avoids duplication of services. • In the event of potential or actual duplication of services, the Case Manager/Clinical Supervisor will contact the disciplines involved and conduct a care conference to correct the situation. The care conference may be conducted via telephone. The results of the care conference are documented and become a permanent part of the patient’s medical record. • Each member of the healthcare team reviews the plan of care at least every four (4) weeks and more often if necessary, based on patient needs and clinical status to evaluate the appropriateness of the plan and the patient’s progress toward goals. • The healthcare team member updates the plan of care as necessary. • The plan of care is dated and signed by the appropriate discipline whenever it is reviewed, even if there are no changes to the plan of care.