Skilled Nursing Facilities

Contents

Creating and Updating Care Plans

You can create a care plan using focuses, goals, and interventions in the provided library to individualize the care plan specific to the resident.  

Care Plans can be created and customized to the resident automatically upon locking an assessment, if configured. Using assessments to create the care plan allows for consistency within your resident chart and the care plan to be created in a timely manner.

You can manually add and remove care plan Items when required to build a comprehensive care plan based on your resident needs.

Warning

Custom care plan items can be used, but should be used sparingly, as custom items are not easily tracked or pulled in reports.

  1. Clinical > Resident > Care Plan.

  2. Note

    If a care plan is not yet created, click New.

  3. Click View Triggered Items Now to review any suggested care plan items. 

    Note

    For more information on managing triggered items, see Managing Triggered Items in Care Plans.

  4. Click New Focus and complete the following steps using the Care Plan wizard:

    1. Select Library.

    2. Select Focus Category.

    3. Click Add to add the focus item in the care plan. 

    4. Select Etiology(ies) and click Next.

    5. Edit Focus for further changes if needed and click Next.

    6. Select Goal(s) and click Next.

    7. Select Intervention(s) and click Save. Items are now part of your resident care plan and the most recent added item appears bold.

  5. Click Edit next to each goal and intervention to personalize for the resident, as needed.

  • You can create interventions within the Care Plan that require specific documentation for Point of Care (POC) or paper care records. For example, restorative nursing interventions that require specific amount of minutes spent in training or skilled practice.

  • Care Plan items that have a SCR_SL_delta.jpg require personalization.

  • If you are trying to add a goal or intervention, but you see no check box:

    • Close popup window and select SCR_SL_show_resolved.jpg.

    • Click Edit next to the goal or intervention.

    • Select Status of Active, make changes as needed, and click Save.