The Collaborative Care Plan allows users to:
Individualize care plans. Users can easily tailor the goals and interventions to the patient, using SmartTools to customize name fields and embedding flowsheets to allow for more documentation of discrete data.
Work across disciplines. Multiple roles can see the care plan, and depending on how an organization configures a particular template, those roles can each edit different parts of the care plan.
See trends in goal progress. Users can hover over a history icon to see information about the last documentation on a goal and click a link to see a summary of all documentation in a goal. An accordion report summarizes prior documentation on all goals.
When a user manually adds a Problem, a Goal, or an Intervention to a patient’s existing Care Plan, the Basic record is used.
Every Problem Template, Goal Template, and Intervention Template requires a corresponding basic record, however, because users can add basic records to a care plan manually, basic records do not require a corresponding template in order to be added to a patient’s existing care plan.
Template records allow basic records to be applied to specific clinical scenarios. Every problem, goal, and intervention template needs an associated basic record. The following information comes from the template records:
The date on which a goal or problem should begin or expire after the care plan is applied
The disciplines of users that can document on a goal
The priority of a goal or problem that displays to users
The problems that are part of a care plan template, the goals associated with those problems, and the interventions associated with those goals
The Duplicate action: what should happen when a user attempts to add the same care plan record to a patient’s chart after it is already applied
Template-specific SmartText (Goals and Interventions)
Template-specific Description (Goals and Interventions)
Basic records are also referred to as “Type” to distinguish from a Template record – for example:
Intervention Type vs. Intervention Template
Goal Type vs. Goal Template
Problem Type vs. Problem Template
When users add an individual Problem, Goal, or Intervention to a patient’s care plan, …………………………….
the basic record is used.
Unlike other records you’ve seen, care plan Problems, Goals, and Interventions have both a ——-record and a —— record. The two types of records are built differently and serve different purposes, though they may represent the same concept for patient care.
Basic records are the building blocks for care plans. These records can be reused in multiple templates. Only problems, goals and interventions have basic records, ———– do not.
basic
template
Care Plans
The following information comes from the basic records:
The ——– of each Problem, Goal, or Intervention
Whether that Problem, Goal, or Intervention can be renamed by a user (this can be overridden by a ——— setting)
————- for lookup
Any flowsheet rows that appear within ———————————————-
display name
Profile
Synonyms
Goals or Interventions
Critical: When a user manually adds a Problem, a Goal, or an Intervention to a patient’s existing Care Plan, the ———record is used.
Every Problem Template, Goal Template, and Intervention Template requires a ———————– basic record, however, because users can add —— records to a care plan —————–,
basic records do not require a ———————- template in order to be added to a patient’s existing care plan.
Basic
corresponding
basic
manually
corresponding
Template records allow basic records to be applied to specific clinical scenarios. Every problem, goal, and intervention template needs an associated basic record. The following information comes from the template records:
The date on which a goal or problem should begin or expire after the care plan is applied
The disciplines of users that can document on a goal
The priority of a goal or problem that displays to users
The problems that are part of a care plan template, the goals associated with those problems, and the interventions associated with those goals
The Duplicate action: what should happen when a user attempts to add the same care plan record to a patient’s chart after it is already applied
Template-specific SmartText (Goals and Interventions)
Template-specific Description (Goals and Interventions)
Basic records are also referred to as “Type” to distinguish from a Template record – for example:
Intervention Type vs. Intervention Template
Goal Type vs. Goal Template
Problem Type vs. Problem Template
Templates allow for a more prescriptive application of a Care Plan for a specific clinical need. When a Care Plan Template is applied, it can also apply Problems with pre-associated Goals, and Goals with pre-associated Interventions.
In many cases, Problems and Goals are generic enough that they may be used in multiple Care Plans. However, depending on the patient’s diagnosis, age, and other factors, the way you achieve the goal, what interventions are associated with the goal and who’s responsible may be different for a specific application of that Care Plan.
Basic records specify generic information that should apply to an intervention, goal, or a problem regardless of the care plan in which it is used. Templates allow you to specify information about a problem, a goal, or an intervention that is unique to a particular care plan template. Some settings can be configured in both the basic record and the template record; in those cases, the template settings override the basic record.
When users add an individual Problem, Goal, or Intervention to a patient’s care plan, the ——- record is used
basic
Sharing basic records allows Epic to perform duplicate checking when a user applies a template. If two templates contain the same basic records, users can choose to Select All Non-Duplicates to add everything except the portions already on the patient’s care plan. In addition, the system can be configured to “merge” duplicate records.
Merging allows the same problem or goal to be added to the patient’s care plan twice. If duplicate goals are merged, when users document on one instance, it automatically documents on the other.
Why Do We Need Both Basic and Template Records?
Templates allow for a more prescriptive application of a Care Plan for a specific clinical need. When a Care Plan Template is applied, it can also apply Problems with pre-associated Goals, and Goals with pre-associated Interventions.
In many cases, Problems and Goals are generic enough that they may be used in multiple Care Plans. However, depending on the patient’s diagnosis, age, and other factors, the way you achieve the goal, what interventions are associated with the goal and who’s responsible may be different for a specific application of that Care Plan.
Basic records specify generic information that should apply to an intervention, goal, or a problem regardless of the care plan in which it is used. Templates allow you to specify information about a problem, a goal, or an intervention that is unique to a particular care plan template. Some settings can be configured in both the basic record and the template record; in those cases, the template settings override the basic record.
Every Problem Template, Goal Template, and Intervention Template requires a corresponding basic record.
Notice that in your new Problem Template record, the ———– field is a required field. This is where the link is made from the Problem Template (LTP) to the Problem Type (INX) for new templates.
Problem Type
Basic Problem Type, Goal Type, and Intervention Type records can be configured to be renamable or not.
It is also possible to configure profile (LPR) settings (I LPR 34078) to allow or disallow renaming.
Who Can Document on a Care Plan?
Discipline is a required field in a Goal Template. Only providers with a discipline that matches one of the disciplines listed in the goal template are allowed to document on that goal added by that template.
Disciplines are records build in the LDS master file and they are assigned in each clinician’s provider record (I SER 34901).
Configuring Interdisciplinary Documentation
Configuring individual care plan goals with the correct disciplines for each can be an overwhelming task. What happens if you overlook a discipline for a particular goal, and someone with that discipline needs to document on it in a patient’s plan of care? For care plan goals that all clinicians should be able to document on, Epic recommends using an “Interdisciplinary” discipline record.
When builders build care plan goals that can be documented on by clinicians of any discipline, they should list the “Interdisciplinary” discipline. This makes the goal editable by any clinician with a discipline listed in their provider record.
Epic’s “Interdisciplinary” Disciplines (LDS) record lists all of the other existing disciplines as Allowable Disciplines for Care Plan Documentation.
Critical The “Interdisciplinary” Discipline record should never be listed as a provider’s discipline in the ———–record.
provider (SER)
True or False: When a user manually adds a problem to a patient’s care plan, the system looks to the problem template to add the problem as well as the goals defined within the template.
False. When problems, goals, or interventions are added manually, the system looks to the basic record, not the template.
True or False: Problems added to a patient’s care plan will also appear in the patient’s Problem List.
False - Care Plan Problems and Problem List diagnoses are distinct.
You can link to SmartTexts in which of the following records?
Intervention (LIT)
Intervention template (LTI)
Goal (INO)
Goal template (IGT)
Problem Template (LTP)
Care Plan Template (LCE)
A. Intervention;
B. Intervention template;
C. Goal;
D. Goal template
Critical:
Basic Problem Type, Goal Type, and Intervention Type records can be configured to be renamable or not.
Problem Type Editor
