Difference between revisions of "Patient Plan of Care~"

Revision as of 07:56, 14 February 2006

Patient Plan of Care

Previously referred to as Nursing Care Plans. The following is a list of terms related to Patient Plan of Care:

Additional Text- Appears as an individual selection for the five basic components of the care plan. It is free text, ranging from 1-245 characters and can be used to clarify or individualize a patient's plan of care. Additional Text does not highlight and no '**' precedes it when selected. Example: ADDITIONAL TEXT: Hard of Hearing.

Aggregate Term- An aggregate term is an element. Throughout the hierarchy of Patient Plan of Care when a selection is made in the development of a patient care plan, that selection is an element/aggregate term. In the Patient Plan of Care site configuration file the same holds true. When prompted with "Select Term to Add," you are adding an element/aggregate term, to that level of the Patient Plan of Care hierarchy. Aggregate terms may be either a Frame or a Term. An example of an aggregate term may be any of the following: altered cardiovascular status, Goals/Expected Outcomes, A-line patent, PA line.

Appended Text- Text that is entered by the user at the end of an element to further clarify the context of the patient data. (For example, if you choose to append the text for SIGNS AND SYMPTOMS OF INFECTION, you could add the terms REDNESS, SWELLING, DRAINAGE, etc., for clarification.).

Classification- A characteristic assigned to one or more aggregate terms in order to link the proper contributing factor Etiology, Goals/Expected Outcomes, Interventions or Related Factors) or parent (Patient Specific Problems). The TERM 'wine with meals' is an Intervention, therefore, the classification is ORDERABLE and is displayed with Treatment Interventions/Orders.

Contributing Factor One of the 5 basic components of a patient plan of care. The 5 contributing factors are:

- 1. Defining Characteristics

- 2. Etiology/related and/or risk factors

- 3. Goals/expected outcomes

- 4. Intervention/orders

- 5. Related problems.

Defining Characteristics Subjective/objective signs and symptoms indicative of a condition corresponding to a given Nursing diagnosis. It is a contributing factor as well as a classification for "Defining Characteristics".

Element A component or an essential part. It can be a TERM or FRAME and comprises the selections used to create a Patient Plan of Care. Example: below the knee amputation or altered cardiovascular status.

Frame This is an element that is general and allows specific items or elements to be selected. A frame contains more selections or terms. Example:

- +A-line (FRAME)

- 1. Calibrate and monitor on Adm. & PRN (TERM)

- 2. Maintain good position of extremity.

Goal A classification used to identify a Goal and/or Expected Outcome. A goal can be measurable or the final outcome of a problem. When used as date for reference or action 'Met' is associated with it.

Goal/Expected Outcome Has two purposes:

- 1. It is a contributing factor (major level), as well as;

- 2. A classification for the "contributing factor" Goals/Expected Outcomes.

Internal Text This is text that can be entered by the user to clarify the meaning of an element. Left and right brackets, [ ], indicate the user will be asked to insert additional text to clarify the element. E.g., V/S q[ ]h, 4 is inserted and text appears as V/S q[4]h.

Intervention The classification for the contributing factor 'Intervention/ Orders'. It links all orders or interventions. Previously, this was named Nursing Interventions.

Lead Text See Glossary Term under Patient Plan of Care "Text".

Max The maximum number of selections that can be selected under a frame. This is normally left blank, when creating a site specific Patient Plan of Care there is no limit to the selections that can be made.

Min The minimum number of selections that can be selected under a frame. The number one (1) is always entered when creating a site specific Patient Plan of Care indicating that at least one (1) selection must be made or the frame will not be included in the care plan.

Orderable A classification that is used to link a name and/or frame to Intervention/Order. Orderable allows you to track the date of initiation and the date of discontinuation.

PPC Patient Plan of Care (Previously called Nursing Care Plan).

Prime Document A classification for the highest level of PPC.

Related Factor The classification for the contributing factor for Related Problems.

Related Problem One of the 5 basic contributing factors of the PPC.

Site Configurable A term used to refer to features in the system that can be modified to meet the needs of each site. The site configuration option allows ADP coordinators to add to "already existing" medical diagnoses/nursing problems.

Tabular The output format for PPC in which the frame and/or document is displayed. There are 3 types of output format, but only tabular is used with PPC.

Term An element used to designate a specific/singular thought or idea. Ex., calibrate and monitor on Adm. & PRN.

Text Lead and trail text are fields which should be used to provide additional information to FRAMES and TERMS usually associated with Intervention/Orders and Nursing Goals/Outcomes. This information, though useful, might exceed the frame's or term's 60 character field.

- 1. Lead Text (for Terms) An example of lead text: The aggregate term under an Intervention should be "assess, monitor and document respiratory rate during activities". The key intervention is "respiratory rate during activities" but for clarity you need to include assess, monitor, and document. Therefore, you can build the aggregate term "respiratory rate during activities" under the frame Intervention/Orders and place the text "assess, monitor, and document" into the lead text field.

- 2. Trail Text (for Terms) Example: The aggregate term under Intervention might be "assess for signs of fatigue and weakness" but you also need to note that the patient should be monitored and that the information must be documented. Therefore, by adding; "monitor and document" as trail text to the aggregate term, the following intervention can be displayed on the care plan: "assess for signs of fatigue and weakness; monitor and document."

- 3. Lead and/or Trail Text (for Frames): Lead and/or Trail Text can be used in a FRAME so that you do not have to keep typing the same word or phrase to TERMS listed under FRAME. Ex. When a user selects the FRAME "refer for appropriate consult", he/she is asked to select the appropriate consult(s). When the Care Plan is printed the word "specifically" is printed following the element. "Specifically" is listed as a Trail Text in the site configuration file. The print would look like "refer for appropriate consult specifically (Physical Therapy, Chaplain)".

Source: Nursing V. 4.0 Technical Manual and Package Security Guide