Assess/Observe
Nursing Diagnosis/Patient Problems
Goals
Teaching Tools
Care Plan Focus
Recommended Frequency
Ordered Frequency
Other Disciplines

Portions of the PO are used in creating a 485 or physician order. Once the pathway is selected, this form is completed during the admission process. It is completed during admission and then updated as needed during the episode.

Assess/Observe: This section is used to identify "extra special" assessment areas that are currently outside of normal limits or have a great risk of being outside normal limits during the episode. Generally, most agencies do a head-to-toe assessment that includes most of the items listed in the assess/observe section. However, the clinician is to identify, by placing a check mark to the left of the problematic assessment item. When known, on the line to the right of the item, the clinician enters the "normal parameters" for the patient. This is critical information to have access to during a visit to improve continuity of care and efficiency of a visit. Special equipment and lab work can also be indicated in this section. This section is used to create a portion of the 485 or physician orders.

Nursing Diagnosis/Patient Problems: These are very common problems for home care patients with the primary condition labeled on the pathway. The clinician may select only a few of the problems or may select all of the problems, depending on the patient and on the planned episode of home care.

Goals: These are very common episodic goals for home care patients with the primary condition labeled on the pathway. The clinician may select only a few goals or select all of the goals, depending on the patient and on the planned episode of home care. This section is used to create a portion of the 485 or physician orders.

Teaching Tools: This space is used to list patient education tools given to the patient. Agencies who have standard packets usually print the titles of the material in the packet in this section and allow the clinician to "check and date" each item as they are given.

Care Plan Focus: This is VNA First’s disease management model. It provides a framework on which to communicate the level of care that is planned or provided or the level of outcomes that the patient has achieved. The levels are safety, disease control and health promotion.

Recommended Frequency: This is the recommended visit frequency for a typical home care patient with the primary condition of the pathway. This is used as a guideline. The clinician, in collaboration with the physician, defines what the actual planned visit frequency will be.

Ordered Frequency: This is the established visit frequency for the episode as determined by the clinician and the physician. The clinician could also include the "planned number of visits" for the episode in this section. This section is also used in the creation of the 485 or physicians orders.

Other Disciplines: This section is to indicate other disciplines in the home and their planned visit frequency and planned number of visits for the episode.