Inpatient Care Plan Documentation
Add Hospital Goals/Plan on Admission
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
Search “hospital” – Select Hospital Goal/Plan
Fill in all sections - may use “patient/family unable”
when applicable for patient/family goal
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
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.