Policy Manual sample

MDT Home Health Care Agency, Inc. 170 CARE PLANNING AND COORDINATION PURPOSE: • To plan and provide individualized care and/or services appropriate to the goals and needs of patients serviced by MDT Home Health Care Agency, Inc. • To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes. POLICY: • An individualized plan of care is developed by Agency licensed staff for each patient based upon an assessment that reflects the patient’s identified problems and needs, consistent with physician or licensed independent practitioner’s orders or prescriptions in accordance with applicable laws and regulations. • When a patient is receiving more than one service, each discipline, i.e., nursing, therapies, social service, including contracted services, develops/contributes to the patient’s plan of care. • Care planning is a collaborative process that takes into consideration the patient’s wishes with regard to medical intervention, treatment choices, family involvement, and if appropriate, end of life decisions. • Care planning is a dynamic process that begins with the admission assessment and continues until the patient’s discharge from the Agency. • Discharge planning is an ongoing process that begins with the patient’s admission for care and/or services. PROCEDURE: • The Registered Nurse and/or Licensed Therapist develops a Patient plan of care within 24 hours of the start of care. • The plan of care includes at least the following information: • List of dates of onset of problems/needs based upon assessment data and physician orders • Measurable, objective goal statements • Interventions to address the identified patient needs