Interdisciplinary Plan of Care

1
Interdisciplinary Plan of Care

• Based on data gathered during patient assessment,
  the Interdisciplinary Plan of Care identifies the
  patients care needs and the strategies to meet
  those needs. It
• documents treatment goals and objectives,
• states criteria for terminating specific
  interventions, and
• documents the patients progress in meeting the
  goals and objectives.
• -- JCAHO, 2003

2
Purpose

• The patient will be transitioned through the
  continuum of care in a seamless, safe and
  effective way. The Plan of Care
• integrates interdisciplinary documentation
  related to discharge planning
• identifies needs, including education
• collaborates and prioritizes care plan goals
• documents resolved issues
• records progress towards discharge

3
Team Roles and Responsibilities

• The team may include
• Nursing
• Occupational Therapy
• Physical Therapy
• Speech Therapy
• Case Management
• Nutrition Dietetics
• Pastoral Care
• Social Work
• Pharmacy

• All team members will
• assess and reassess patients
• document needs and goals, as well as strategies
  and interventions
• Nursing initiates the process by setting the
  first goals

4
Process Used

• Gather data during patient assessment and
  reassessment
• Identify and document patient care needs and
  goals (need minimum of 2 goals)
• Develop strategies and interventions to meet
  identified needs and goals
• State criteria for terminating interventions

5
Identifying Care Goals -- An Example

• Albert Jones, an 85 year old male, came to the
  TJUH Emergency Dept. with chest pain. He was
  diagnosed with Aortic Stenosis and admitted to
  the Medical Coronary Care Unit. His known
  history includes
• Type 2 Diabetes Mellitus- Now Insulin Dependent
• Rheumatoid Arthritis (30 years)
• difficulty climbing stairs
• widower of 6 years
• attends mass daily
• Identify your care goals!

6
Sample Set of Goals

• Within 24 hours of treatment, patient will have
  adequate cardiac output (Nurse)
• Patient will maintain blood glucose levels of
  lt120 (Nurse)
• Patient will report Pain Level lt3 (Nurse)
• Patient will ambulate 10 ft. without assistance
  (PT Nurse)
• Patient will demonstrate proper use of assistive
  devices prior to discharge (PT)
• Family will receive bereavement ministry
  (Pastoral Care)
• Home care will be coordinated with anticipated
  discharge within 3 days (Case Management)
• Patient will demonstrate proper insulin self
  injection techniques (Nurse)
• Patient will verbalize proper diet, CHO counting
  for diabetes (Dietician)

7
Ongoing Team Responsibilities

• Nursing prioritizes stated needs and goals daily
• All Interdisciplinary Team members
• document on the Interdisciplinary Plan of Care
  form (located in chart behind pink tab)
• regularly review treatment goals
• identify education needs during initial
  assessment
• document education on form e.g.
• diabetes instructions
• diabetes education JET TV Channel