Care Plan: Development, Monthly Update and Review Every 15 Days

In short

• Every patient and family has one written plan of care set by the team under the attending physician's orders.
• The plan states the diagnosis and prognosis, problems and goals, how often each service happens and who gives it.
• The team reviews each plan at least every 15 calendar days and does a full update every month.
• Involve the patient and caregiver and record how well they understand and agree.
• If a plan change affects what the hospice does not cover, update the addendum within 3 days.
• Send the current plan to the inpatient unit or facility when the patient goes there.