Details

Care Plan Detail

Client is a new admission with discharge potential. Stay projected to be of short duration, and client plans d/c to: [__] Home [__] Assisted Living

Description
The client, a recent ... Please Login or Join to access this information
Record Id
280
Code
00280
Downloads
142
References
Diane Carter & LeeAnna Spiva. (2017). A comprehensive discharge planning process: Relevance and value. Nursing Clinics, 52(3), 359-367. https://doi.org/10.1016/j.cnur.2017.04.001
S. Appel, E. Gil, G. Warshaw, & E. Snow. (2021). Transitional Care for Older Adults: A Research Agenda. The Gerontologist, 61(4), 514–522. https://doi.org/10.1093/geront/gnaa186

Outcomes

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Will successfully transition from ... Please Login or Join to access this information
Description: Client will smoothly ... Please Login or Join to access this information
Rationale: This nursing outcome ... Please Login or Join to access this information
Record Id
1554
Downloads
12,921
Evaluate in days
90
Evaluation Date
06/15/2026
Outcome References
Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2019). Continuity of Care: The Transitional Care Model. Online Journal of Issues in Nursing, 24(3). https://doi.org/10.3912/OJIN.Vol24No03PPT54
Altfeld, S.J., Shier, G.E., Rooney, M., Johnson, T.J., Golden, R.L., Karavolos, K., Avery, E., Nandi, V., & Perry, A.J. (2018). Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial. Gerontologist, 58(4), 670–679. https://doi.org/10.1093/geront/gnw202

Actions

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Nursing, social services and ... Please Login or Join to access this information
Description: Weekly review and ... Please Login or Join to access this information
Rationale: Regular meetings ensure ... Please Login or Join to access this information
Record Id
2215
Downloads
21,483
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SW to visit weekly ... Please Login or Join to access this information
Description: A weekly visit ... Please Login or Join to access this information
Rationale: Weekly SW visits ... Please Login or Join to access this information
Record Id
2216
Downloads
21,483
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Encourage client and family ... Please Login or Join to access this information
Description: Promotes active participation ... Please Login or Join to access this information
Rationale: Involving clients and ... Please Login or Join to access this information
Record Id
2217
Downloads
21,483
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SW to contact preferred ... Please Login or Join to access this information
Description: The social worker ... Please Login or Join to access this information
Rationale: The Social Worker ... Please Login or Join to access this information
Record Id
2218
Downloads
21,483
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Make referrals to other ... Please Login or Join to access this information
Description: This involves the ... Please Login or Join to access this information
Rationale: Referring to other ... Please Login or Join to access this information
Record Id
2219
Downloads
21,483
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Discuss with rehab any ... Please Login or Join to access this information
Description: Engages in dialogue ... Please Login or Join to access this information
Rationale: Ensuring special equipment ... Please Login or Join to access this information
Record Id
2220
Downloads
21,483
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Notify MD of discharge ... Please Login or Join to access this information
Description: Involves prompt communication ... Please Login or Join to access this information
Rationale: Quickly informing doctors ... Please Login or Join to access this information
Record Id
2222
Downloads
21,483
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Assure client/family of facility’s ... Please Login or Join to access this information
Description: Involves reassuring the ... Please Login or Join to access this information
Rationale: To maintain trust ... Please Login or Join to access this information
Record Id
2223
Downloads
21,483