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Inpatient Care Plan Documentation

Inpatient Care Plan Documentation - Clinical Hub, Nursing Hub, Nursing Practice Tools and Resources, Resources

Updated 9/8/2017

Inpatient Care Plan Documentation
 Add Hospital Goals/Plan on Admission
 Update Daily
 Complete at Discharge
 Initiate/Update Longitudinal Goals
Add Hospital Goal/Plan on Admission
1) Within the Care Plan activity, add Hospital Goal/Plan template

2) Complete template; review every shift, update daily and as needed

3) Document “Goal/Plan Progress” and “Goal/Plan Reviewed With” Daily by using Smartlists
 To change what was documented previously, right click on the text and choose “re-select this
SmartList’s Selections”

Search “hospital” – Select Hospital Goal/Plan
Fill in all sections - may use “patient/family unable”
when applicable for patient/family goal

Updated 9/8/2017

Completing Hospital Goal/Plan at Discharge
When the patient is ready for discharge, the nurse should complete the Hospital Goal/Paln. To do this
from the Discharge Navigator, the nurse should:
1. Select Goals
2. Click to open the Hospital Goals/Plan comments
3. Update Goal and Plan Progress
4. Click on the Complete Goal button

Longitudinal Goals
If patients have goals that they plan to continue working toward after discharge from the hospital,
inpatient staff can enter these goals using the same Patient Goals Activity.
1. Select or “Add” a goal topic
2. Free text the patient-stated goal into the Goal field: I will ……….
3. Complete the smarttext (DO NOT DELETE), and click Accept.