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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 ...
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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
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
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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
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
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
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
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
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
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
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
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
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