The Comprehensive Plan of Care (POC) enables hospice clinicians to access and review pertinent information in one convenient document. The Comprehensive POC consolidates physician orders, discipline frequencies, demographic information, supplies, emergency preparedness, advance directives, and medical equipment needs.
Users can view, download, and print the Comprehensive Plan of Care for documentation purposes and to ensure seamless communication between clinicians and other hospice providers to facilitate appropriate changes and overall coordination of care on an ongoing basis.
Create the Comprehensive Plan of Care by assessing and documenting patient needs in the Initial Assessment or Initial/Comprehensive Assessment. Once created, document all updates and changes in the Updated Comprehensive Plan of Care. All users can view, download, and print the Comprehensive Plan of Care as needed.
To access a patient’s Comprehensive Plan of Care, navigate to the Patients tab and select Plan of Care from the drop-down menu.
Patients tab ➜ Plan of Care
Users can also access the Comprehensive Plan of Care through the Patient Charts.
Patients tab ➜ Patient Charts ➜ Actions menu ➜ Plan of Care
The Plan of Care Profile displays the patient’s active problem statements and the Comprehensive Plan of Care.
To print or download the Comprehensive Plan of Care, navigate to the patient’s chart and click the printer icon next to the Plan of Care under Actions. The Plan of Care will open in a PDF that users can print and/or save electronically.
Patients tab ➜ Patient Charts ➜ 
To update clinical aspects of the Comprehensive Plan of Care, a physician order must be in place.
Physician orders can be created through any of the following locations:
For instructions on creating a physician order, visit the Physician Orders page of the Help Center.
The Plan of Care Profile can be updated through a physician order that was created through a clinical document or scheduled through the Patient/Employee Schedule.
To update the Plan of Care Profile, click the Plan of Care button under Order Types in the physician order.
The Plan of Care Profile can also be updated by selecting Update Plan of Care in the Plan of Care Profile.
When the Update Plan of Care button is selected, the system prompts the user to select or add a physician order to link the updates. To add a new physician order, click Create on the right side of the New Physician Order tile and enter a date for the new order in the Date field.
Once a physician order has been selected or created, a blue confirmation message appears at the top of the screen with the order’s date and assigned user.
In the editable Plan of Care Profile, users can update problem statements and add problems using the corresponding buttons:
To add a new problem, click Add Problems. Select a problem area in the Select Problem Area drop-down menu and click Add. Problem areas that are not currently on the Plan of Care Profile appear in the menu for selection.
Enter the problem statement, goals, and interventions. All sections are editable, so users can fully customize the Plan of Care Profile based on the specific needs of each individual patient and family.
Replace any text that appears between **double asterisks** with individualized patient information to customize the Plan of Care.
Under each selected goal, select one of the following options to identify the goal length:
When entering interventions for a goal, identify which of the following disciplines is responsible for completing the intervention:
Once all problem statements, goals, and interventions have been entered, click Complete at the bottom of the screen. The problem statements, goals, and interventions will update in the Plan of Care Profile and flow to the physician order document.
A green success message will confirm that the problem was added.
To discontinue interventions and resolve goals, select Update Problem Statements in the Plan of Care Profile. The Plan of Care Profile will open in this view:
To resolve a goal, select one of the following options from the Select to Resolve drop-down menu:
To discontinue an intervention, select Discontinue to the right of the intervention. Marked to Discontinue will appear in black text. Click the blue Save button to finish discontinuing the intervention.
If you hit the Discontinue button inadvertently, or decide not to discontinue the intervention, click the red Cancel button.
An intervention cannot be discontinued if it is the only intervention associated with a goal. Every goal must have at least one intervention. The Discontinue option will not appear for an intervention unless at least one other intervention is associated with the goal. When only one intervention is associated with a goal, No Actions will appear in the Actions column.
Each intervention must be associated with a goal. If you select to resolve the only goal associated with a problem statement, the problem area and all associated interventions will be marked to discontinue.
The Save button in the top right of the Plan of Care Profile shows the number of problem statements, goals, and interventions impacted. Click Save to complete the actions (or Cancel to stop the actions).
Once saved, a green success message will confirm that the Plan of Care was updated successfully.
Updates to the problem statement, goals, and interventions will appear in the Plan of Care Profile and flow to the physician order.
To add new goals and interventions to an existing problem area, select Edit next to the problem area in the Plan of Care Profile.
Level of care can only be updated through a physician order document. To update the level of care:
Once the physician order is complete, the new level of care will replace the previous level on the Comprehensive Plan of Care and in the Patient Chart header.
Discipline frequency is updated through the physician order to ensure that all frequencies have a corresponding order. In the physician order document, click the Frequency button to update visit frequencies.
The patient’s Frequency Profile will open to display the discipline, visit frequency, PRN status, start date, and end date for the patient’s active and discontinued frequencies.
To add a new frequency, click the Add Frequencies button in the top right corner. Complete the fields under Add Frequencies:
Actions for existing frequencies include Discontinue, Discontinue and Copy, and Copy. Selecting Discontinue will prompt you to enter a discontinue date for the frequency. If you click this by mistake, click Cancel and the frequency will not be discontinued.
Select Discontinue and Copy to update an existing frequency by creating a discontinue order for the frequency and copying it so that only the necessary changes need to be documented. Selecting Discontinue and Copy will prompt you to first enter a discontinue date. Once entered, the visit frequency, start date, PRN, and reason for PRN can be updated as needed.
Discontinued frequencies can be restarted using the Copy action. To restart a discontinued frequency, click Copy and enter a new start date. The visit frequency, PRN, and reason for PRN will pre-populate with data from the copied frequency. Update these fields as needed and click Save.
Frequencies can also be updated directly through the Frequency Profile. Navigate to the Frequency Profile through the Patients tab.
Patients tab ➜ Frequency Profile
When updating frequencies in the Frequency Profile, select or create a physician order to attach your updates, and follow the process above to update the visit frequency as n