Policy Manual sample

MDT Home Health Care Agency, Inc. GUIDE FOR MEDICAL PLAN OF CARE All clinical services are implemented only in accordance with a plan of care established by a physician’s written orders. We accepts physician’s orders on referral communicated verbally by an institution’s discharge planner, nurse practitioner, physician’s assistant, or other authorized staff member followed by written, signed and dated physician’s orders, in order that our patients are to begin services as soon as possible. We accepts signed physician certification and recertification of plans of care, as well as signed orders changing the plan of care, by telecommunication systems (“fax”), which are filed in the clinical record. The plan of care must be established and authorized in writing by the physician based on an evaluation of the patient’s immediate and long term needs. Our staff, and if appropriate, other professional personnel, shall have a substantial role in assessing patient needs, consulting with the physician, and helping to develop the overall plan of care. The patient has the right, and should be encouraged, to participate in the development of the plan of care before care is started and when changes in the established plan of care are implemented. Our Agency permit a podiatrist to establish and recertify a patient’s plan of care. The podiatrist’s functions must be consistent with our policies and procedures that pertain to therapeutic activities he/she is legally authorized by the State to perform. All orders for therapy services must include the specific procedures and modalities to be used and the amount, frequency, and duration of the therapy ordered. 1. The medical plan of care will be used to identify clinical problems and to develop plans for individual skilled care. 2. All skilled personnel will use this form to record information for reference regarding the patient care for which they are responsible. How the Medical Plan of Care is made out or developed: 1. All skilled personnel involved in the care of the patient should observe, listen, etc. in order to identify the patient's problems or needs. 2. These problems or needs should be identified on the patient's chart. 3. If the skilled personnel identifying the patient problem has a plan to meet this need, he or she should develop it. If she does not have a plan to meet this need, the staff should discuss it and make suggestions or plans. These suggestions or plans should be written in the patient's chart for all skilled personnel to see and use in caring for the patient. 4. Medical personnel resources such as the patient's physician, a dietician, the aide, etc. should be consulted by the nursing personnel to help in more thoroughly understanding the patient's needs and develop plans for meeting then whenever indicated. Guide for Medical Plan of Care: 1. Physical care and instructions for carrying out physical care (e.g. "left knee joint painful; handle carefully"). 2. Plans and progress of plan for patient teaching (e.g. teach patient colostomy care; let patient observe nurse giving colostomy care; instruct patient how to irrigate colostomy today, and support him while he irrigates his colostomy). 3. Types of observations to be made, reasons for them, and what they mean. Home Health Agency Nursing Care & Procedures K-5