The Comprehensive Care Plan covers the key risk areas of Falls, Pressure injury, Nutrition and Cognition and will now be suggested in the EMR for all admitted adult and paediatric inpatients and must be initiated and individualised to meet patients’ needs.
The advantages of the Comprehensive Care plan
- No requirement to complete Falls, Pressure Injury, Nutrition and Cognition risk assessments for inpatients
- It is designed to facilitate time critical documentation
- It provides a consistent single Care Plan for nurses who are working across different wards and units
- It provides a single Care Plan aligned to the current hospital environment in which all admitted patients are deemed “at risk “.
- Does not apply to excluded areas: Newborn, Day Treatment, and areas that do not currently use EMR care plans
Instructions
With the Comprehensive Care Plan, nurses will not need to complete the risk assessments tasked on admission. All patients will be deemed “at risk”, therefore on admission select “not done” for risk assessment. Then go straight to creating the Care Plan to meet the patient’s needs.
Risk Assessments will not be performed routinely and are only required if deemed necessary to identify an alteration in status.
For patients with a pressure injury, document this in the wound section of iView and ignore the suggested pressure injury management care plan suggested by the EMR.
For patients who have had a fall, document in iView as normal and ignore the suggested falls management care plan. Complete the Post Fall Review form and add additional requirements to the Comprehensive Care plan via “add to phase” if required.
Exclusions for using the Comprehensive Care Plan
- Newborn, Day Treatment, and areas that do not currently use EMR care plans
- Newborn (Nest and SCU) will continue to perform risk assessments
Initiating other care plans
While there is no need to initiate care plans for Falls, Pressure Injury, Nutrition and Cognition, other Care Plans are to be initiated where clinically appropriate e.g. pain management care plan
Find out more in the Comprehensive Care Plan QRG
Approved by Denise Owen