Care Plan Review Explained

Care Plan Review Explained

The resident Care Plan can be Reviewed in two separate locations:

1. Through the Residents menu
2. Through the Documentation menu

Through the Resident menu, you can select a resident and select the Care Plan tab. In this view, you can view the Summary, Extended or Evaluate Care Plan views.

Through the Documentation menu, you can search for a resident and select the relevant link to view the Care Plan. Through the documentation menu you can view Active, Historical or Unfinished versions of a Resident's Care Plan.

1. Evaluating a Resident's Care Plan
2. Evaluate Care Domain
3. Evaluate Goals and Interventions
4. Add Observations, Goals or Interventions
5. Move and Link Observations, Goals and Interventions
6. Strikethrough Observations, Goals and Interventions
7. View and Update The Assessment Form From Care Plan

Evaluating a Resident's Care Plan

View Through The Residents Menu

• Click Residents
• Search for your Resident
• Click the Care Plan tab
• Click the Evaluate button

View Through The Documentation Menu

• Click Documentation
• Browse to the Care Plans section
• Click View / Evaluate Care Plans
• Search for your Resident
• Click the Evaluate button next to their name

Evaluating a Care Domain

Each Care Domain within a Resident's Care Plan can be evaluated. 

• Ensure you are looking at the Evaluate view of a Resident's Care Plan
• To the right hand side of a Care Domain click Evaluate Care Domain
• Select an Outcome
• Enter some Notes
• Enter your Password
• Click Save

Once you have finished Evaluating the Care Domain and the save button is selected:

• A Progress Note will be written stating an evaluation has been completed
• The Care Domain banner will display with the ‘Last evaluation date’
• The evaluation note section can be minimised or maximised within the Care Domain
• The evaluation note can be struck through (based on permissions)
• The Care Plan evaluation date will be updated to today’s date
• When multiple evaluation notes have been made over a period of time they will display newest to oldest

Evaluate Goals and Interventions

Each Goal and Intervention within a Resident's Care Plan can be evaluated.

• Ensure you are looking at the Evaluate view of a Resident's Care Plan
• To the right hand side of a Care Domain click the expand (+) icon 
• The above action will display all active Observations, Goals and Interventions associated with the expanded Care Domain
• Below the Goal or Intervention that you wish to Evaluate, click Evaluate
• Select an Outcome
• Enter some Notes
• Enter your Password
• Click Save

Add Observations, Goals and Interventions

Through the Care Plan Evaluate view an Observation, Goal or Intervention can be added to the resident Care Plan at any time. 

Add Observations, Goals and Interventions

• Ensure you are looking at the Evaluate view of a Resident's Care Plan
• To the right hand side of a Care Domain click the expand (+) icon 
• The above action will display all active Observations, Goals and Interventions associated with the expanded Care Domain
• To the right-hand side of the words Observation, Goal and Intervention you will see the words "Add New"
• Click Add New
• Enter the new Observation, Goal or Intervention as appropriate
• Click Save
• The new Observation, Goal or Intervention you entered will now appear
• You can move it's position by using the grey three lines icon  

Move and Link Observations, Goals and Interventions

When in the Care Plan Evaluate view you can select to move the order of Observations, Goals or Interventions. In addition you can Link Goals to Interventions.

Move Observations, Goals and Interventions

• Ensure you are looking at the Evaluate view of a Resident's Care Plan
• To the right hand side of a Care Domain click the expand (+) icon 
• The above action will display all active Observations, Goals and Interventions associated with the expanded Care Domain
• You can use the grey three lines icon  to drag and drop the responses into a new order

Link Goals and Interventions

• Ensure you are looking at the Evaluate view of a Resident's Care Plan
• To the right hand side of a Care Domain click the expand (+) icon 
• The above action will display all active Observations, Goals and Interventions associated with the expanded Care Domain
• You can use the grey three lines icon  to drag and drop an Intervention onto a  Goal in order to link them
• Once successfully linked a link icon will appear

Strikethrough Observation, Goals and Interventions

Through the Care Plan Evaluate view, you have the ability to strike through various bits of information (Observations, Goals, Interventions and Evaluation Notes). 

• Ensure you are looking at the Evaluate view of a Resident's Care Plan
• To the right hand side of a Care Domain click the expand (+) icon 
• The above action will display all active Observations, Goals and Interventions associated with the expanded Care Domain
• Below the Observation, Goal or Intervention that you wish to strike through, click Strike Through
• Enter a Reason
• Enter your Password
• Click Save

View and Update The Assessment Form From Care Plan

When an Observation, Intervention or Goal has been added to the Care Plan via an Assessment Form, a blue document icon will display.

If you hover over the this icon you can view the Username, Designation, Date/Time and Assessment Form that was used to generate the response.

If the information is not accurate either out of date or you spot a mistake (spelling ...), you can click on the Assessment Form name in order to open the Assessment Form. The Assessment Form details can then be updated and completed, and the Care Plan will also be updated immediately with the changes.

Any Assessment Form data that is not dynamically updated to the Care Plan but has been added to the Care Plan via the Care Plan Builder will display with a red icon and if changed will not update unless a new Care Plan is completed through the Care Plan Builder.