By Lisa Werner
It is important to keep the patient’s plan of care at the heart of the team’s decision making. While each team member creates their own discipline-specific plan of care, it is incumbent on each member to know what the plans written by other team members include. Each team member is responsible for ensuring continuity of care in order to effectively and efficiently achieve the best outcome in the shortest amount of time. To do this, all team members must work together. Be sure that your team conference includes a review of the patient’s plan of care, barriers to achieving the plan, and strategies to help the patient progress with his/her plan.
One way that I have seen this achieved is by having the therapists complete a weekly progress note that subsequently populates the team conference note. The progress notes may include current status with goals, barriers to discharge, and updates to the goals. While this is generally the format for therapists, there does not appear to be a consistent approach for nurses to do the same. This seems to be a missing link for many providers. I encourage you to consider ways to pull the nursing team into the plan of care discussion. Each member should come to team conferences ready to share their updated plan and priorities for the week, and should leave with additional plans and priorities as stated during the conference by the nurse, other therapists, and adjunct team members such as psychology, therapeutic recreation and nutrition services.
How are you communicating updates to the plan of care and priorities for the week? Take this idea back to your team and discuss strategies that might work for you. Maintaining continuity of care is a critical element of the patient’s progress. See what you can do to improve that in order to achieve the best possible outcomes.