Section 325.20709. Patient care planning.

(1) Nursing care provided to each patient in  a  nursing   home shall be based on all of the following:

(a)   Written assessment of the patient.

(b)   Identification of health problems.

(c)   A written plan of care or intervention.

(d)  Implementation of the care plan.

(e)   Evaluation of the results of the planned care or intervention.

(2)    An assessment of a patient shall be initiated by licensed nursing personnel within 24 hours of admission, and the results of the assessment shall be documented in the patient's clinical record.

(3)   The written plan of care  shall  be  available   to  all  individuals involved in the care of the patient and shall  document  all  of  the following:

(a)   The patient's problems and needs.

(b)   Goals and objectives of care.

(c)   Methods of approach to care.

(d)  Treatment and orders.

The disciplines responsible for each element of care shall be identified in the plan. The written plan of care for a patient shall be considered to be part of the patient's clinical record and shall be included with  the record at the time of discharge.

(4)    The patient care plan shall    be   reviewed    and   the   care   shall   be evaluated periodically, as required,  to  reflect  the  patient's  current condition.

(5)   The nursing home shall make reasonable efforts to  discuss  the patient care plan with the patient, next of kin, guardian, or designated representative so that such parties can contribute to the   plan's development and implementation.

(6)    A patient care conference shall be held periodically, but not less than once every 90 days, to evaluate a patient's needs and to provide for the appropriate   revision of the patient care plan while promoting continuity of care. The patient care conference shall include representatives from the professional disciplines providing services to the patient, and observations and recommendations of the health professionals participating in the patient care conferences shall be summarized in the patient's clinical record or plan of care.

History: 1981 AACS; 1983 AACS; 1984 AACS.