Collaboration for Improving Outcomes – Discharge Plan Des.docx
- 1. Collaboration for Improving Outcomes – Discharge Plan Description: The baccalaureate graduate nurse will conduct a health history to identify current and future health problems. Course Competencies: 2) Develop a holistic case management plan for a specified disease or population that incorporates the role of insurance, health care finance, and utilization of community resources. 4) Coordinate the care of individuals across the lifespan utilizing principles and knowledge of interdisciplinary models of care delivery and case management. QSEN Competencies: 1) Patient-Centered Care 2) Teamwork and Collaboration 3) Evidence- Based Practice BSN Essential VII Area Gold Mastery Silver
- 2. Proficient Bronze Acceptable Acceptable Mastery not Demonstrated Assessment • General Information • Current Medications • Activity of Daily Living • Patient Support System • Medical Follow-up • Financial Summary Completes all sections of the
- 3. assessment Completes half of the elements of the assessment. Completes less than half of the elements of the assessment Elements are superficially addressed or are missing. Diagnosis/Plan • Priority • Nursing Diagnosis
- 4. • Client Outcomes/Goals Completes all elements of the diagnosis/plan Completes half of the elements of the diagnosis/plan Completes less than half of the elements of the diagnosis/plan Elements are superficially addressed or
- 5. are missing. Education Needs • Need • Method • Evaluation Completes all elements of the education needs Completes half of the elements of the education needs Completes less than half of the elements of
- 6. the education needs Elements are superficially addressed or are missing. Financial Worksheet • Future Medical Care -routine -specialty -Tx interventions • Medication Needs
- 7. • Supplies • Diagnostic Testing • Future Adjunctive Tx • Medical Equipment • Transportation • Home Furnishings & Adaptations • Potential Complications • Financial Summary Completes all elements of the financial worksheet Completes half of the elements
- 8. of the financial worksheet Completes less than half of the elements of the financial worksheet Elements are superficially addressed or are missing. Reflection and Conclusion Interprets the complete format and
- 9. develops a conclusion for the plan of care Reviews the format and does not fully develop a conclusion for the plan of care Defines the format and does not present a conclusion Does not provide an interpretation of the format
- 10. and/or no conclusion for plan of care. APA, Grammar, Spelling, and Punctuation No errors in APA, Spelling, and Punctuation. One to three errors in APA, Spelling, and Punctuation. Four to six errors in APA, Spelling, and
- 11. Punctuation. Seven or more errors in APA, Spelling, and Punctuation. References Provides two or more references. Provides two references. Provides one references. Provides no references. I. ASSESSMENT Name: Click here to enter text. DOB: XX/XX/XXXX Date of Admission: Click here to enter a date.
- 12. Assessment Date: Click here to enter a date. Admitting Diagnosis: Click here to enter text. Past Medical History (include surgical history) Click here to enter text. Subjective history of current hospitalization (what led to current hospitalization?) Family and social history Click here to enter text. Summary of physical assessment (complete head-to-toe from hospitalization documentation) Click here to enter text. Allergies: Click here to enter text. Effects of diagnosis on daily living: Click here to enter text. Current Medications (to add rows, click “insert row” on Table Layout tools) Name Dose Schedule Last taken
- 13. Activity of Daily Living and Instrumental Activity of Daily Living Assessment (Place an “X” in the appropriate column) Activity Not applicable Dependent Semi Independent Bathing Dressing Personal Cares
- 15. Food Preparation Managing Medications Using the Phone Housework Laundry Transportation Managing Finances Total
- 16. Patient Support System (based upon above assessment, who is available to provide care or support to patient) Name Relationship AvailabilityClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text. Medical Follow-upClick here to enter text. Financial SummaryClick here to enter text. II. DIAGNOSIS/PLAN List your top three priorities, create a nursing diagnosis, and create two goals for each Priority 1. Click here to enter text. 2. Click here to enter text. 3. Click here to enter text. Nursing diagnosisClick here to enter text.Click here to enter text.Click here to enter text. Client outcomes 1. Click here to enter text. 1. Click here to enter text. 1. Click here to enter text. 2. Click here to enter text.
- 17. 2, Click here to enter text. 2. Click here to enter text. III. EDUCATION NEEDS Need Method Evaluation of learningClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text. I. Future Medical Care - Routine Routine Care Description Frequency of visits Purpose Cost per visit Cost per year IV. FINANCIAL WORKSHEET Subtotal II. Future Medical Care - Specialty Description Frequency
- 18. Purpose Cost per visit Cost per year Subtotal III. Future Medical Care – Treatment Interventions Recommendation Frequency of procedure Purpose Cost per procedure Cost per year
- 19. Subtotal IV. Medication Needs Name/dose Schedule Purpose Cost per month Cost per year Subtotal V. Supplies Supplies Schedule Purpose Cost per month Cost per year
- 20. Subtotal VI. Diagnostic Testing Diagnostic Test Schedule Purpose Cost per month Cost per year Subtotal VII. Future Adjunctive Therapies Therapy Purpose Frequency Cost per month Cost per year
- 21. Subtotal VIII. Medical Equipment Equipment Purpose Purchase/Rental Cost per month Cost per year Subtotal IX. Transportation Mode Purpose Purchase/PRN Cost per month Cost per year
- 22. Subtotal X. Home Furnishings and Adaptations Need Purpose Initial cost Upkeep Final cost Subtotal XI. Potential Complications Complication Estimated Cost
- 23. Subtotal Financial Summary Description Cost per Year Non-recurring cost I. Future Medical Care - Routine II. Future Medical Care - Specialty III. Treatment Interventions IV. Medication Needs V. Supplies VI. Diagnostic Testing VII. Future Adjunctive Therapies VIII. Medical Equipment IX. Transportation X. Home Furnishings and Adaptations
- 24. XI. Potential complications TOTAL: V. REFLECTION AND CONCLUSION