Problems are identified from the initial medical and nursing assessments for each patient, and a plan of care (POC) is implemented soon after by the responsible physician, nurse, and other health professionals with the involvement of the patient and family to address these problems using the data from the initial assessments.

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The POC is a written guide that organises data about a patient’s care into a formal statement that will be used to help the patient achieve optimal health. Therefore, a carefully formulated written plan of care is developed within 24 hours of admission as an inpatient in order to provide quality patient care by prioritising problems and addressing short- and long-term needs of the patient by prioritising treatments, setting realistic goals and developing expected outcomes (outcome identification), planning medical and nursing interventions (with collaboration and consultation between care providers as needed) to meet the patient’s needs, and finally documenting the care plan.

Systematic monitoring and observation performed by the patient’s health care practitioners related to specific problems during ongoing assessments (reassessment) allow to determine the patient’s response to medical and nursing interventions and to identify any emerging problems so as to update the plan as appropriate or to confirm the validity of the data obtained during the initial assessments, thus allowing in compiling a comprehensive database of the patient’s health to achieve the desired outcomes.

Reassessment detect the patient’s changing needs as the result of clinical improvement or new information from a routine reassessment (for example, abnormal laboratory or radiography results), or they may be evident from a sudden change in the patient’s condition (for example, loss of consciousness). The plan for the patient’s care also changes.

The Joint Commission International (JCI) Standard COP.2.1 requires the documentation of a single, integrated care plan that identifies measurable progress (goals) expected by each discipline as opposed to the entry of a separate care plan by each practitioner. This individualised plan of care related to his or her identified needs must be evident for each patient in the patient’s medical record.

During the accreditation survey, the reviewer looks for evidence of an organised and systematic method of monitoring and evaluating patient care that is reflected through changes in the documentation of the medical record as notes to the initial plan or as revised or new care goals, or in a new plan.

The Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status must ensure that all medical records are complete with a  POC.

Medical records will be used to proof evidence of POC for each patient to fully meet the seven (7) requirements for this standard which ensures compliance with JCI’s plan of care requirements as follows :

1. The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of admission as an inpatient
2. The planned care is individualised and based on the patient’s initial assessment data
3. The planned care is documented in the record in the form of measurable progress (goals)
4. The anticipated progress (goals) is updated or revised, as appropriate, based on the reassessment of the patient by the interdisciplinary health care practitioners
5. The care planned for each patient is reviewed and verified by the responsible physician with a notation in the progress notes
6. The planned care was provided
7. The care provided for each patient is written in the patient’s record by the health professional providing the care

Since Standard COP.2.1 clearly states the POC provided to each patient is planned and written in the patient’s record by the health professionals providing the care, justifies this standard to be included as medical information.

References :
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10^th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA