Policy Manual sample

MDT Home Health Care Agency, Inc. 171 • Interventions, including teaching and training guidelines, are appropriate to the scope of practice of the individual developing and/or updating the plan of care and consistent with relevant clinical practice guidelines • Measurable patient outcomes • The Case Manager/Clinical Supervisor receives a verbal summary of the plan of care on the day of the initial/assessment visit. • The original signed 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. • Copies of the plan of care are distributed to all members of the healthcare team who are providing care and/or services to the patient. • The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process to ensure that the plan is appropriate and realistic, based on the patient’s needs and clinical status and to promote positive outcomes, and to avoid duplication of services. • In the event of potential or actual duplication of services, the Case Manager/Clinical Supervisor contacts the disciplines involved and conducts 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. • The plan of care is reviewed, updated and/or modified at least every four (4) weeks and more often if necessary. 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. • Any reviews of and/or changes to the plan of care are dated and signed by the appropriate discipline whenever it is reviewed, whether or not there are changes to the plan of care. Any changes are communicated to other members of the healthcare team either verbally or in writing. • The physician is contacted as necessary and appropriate with reports of changes in the patient’s clinical status and/or needs, and for necessary orders and/or prescriptions. • Problem resolution dates are recorded as achieved. • Verbal care conferences conducted on an impromptu, as-needed basis should be documented in the visit notes of each of the disciplines involved. • Multidisciplinary care conferences are held on selected patients at least monthly and more frequently if needed, to promote coordination and continuity of care. The results are documented and a copy is retained in the patient’s medical record.