RN Treatment Plan Review Neil Brouwer BSN RN

RN Treatment Plan Review Neil Brouwer BSN, RN BC

• Outline: – Decoding the Jargon – Adding the Medical Problems to Initial MTP – Adding the Medical Problems to Care Plan – Other Considerations

Decoding the Jargon What is the Initial MTP? The Initial Master Treatment Plan is the document, started at admission, that contains assessment data and contributions from each discipline.

Decoding the Jargon What is significant about the nursing portion of the Initial MTP? The assessment and contribution from Nursing in the Initial MTP has extra significance, because it establishes, from admission, the measures taken to ensure patient safety during the period while the MTP and Care Plan are being fully constructed.

Decoding the Jargon What is the Care Plan? The Care Plan (accessed through the Care Planning activity) contains the specific Problems, Goals, and Interventions (Psych and Medical) relevant to the patient during this admission.

Decoding the Jargon What is the Multidisciplinary Plan of Care? The title of the care plan. *Add both medical and psych problems under one multidisciplinary plan of care - do not add a second if one is already created!

Decoding the Jargon So what’s the connection between the Initial MTP and the Care Plan? The Care Plan is embedded within the Initial Master Treatment Plan. Scroll Down

Decoding the Jargon What is an MTP Update? A document, created by Case Manger, updating the patient’s progress. Rather than remaking a new version of the Initial MTP, the update addresses specific questions related to progress of the Initial MTP.

Decoding the Jargon Why is an MTP Update Needed? The Initial MTP expires in 9 -12 days. MTP Updates expire after only 1 week. BUT…. Significant events such as restrictive measures, new or worsening medical conditions, or ER visits require an earlier MTP update.

Decoding the Jargon So Exactly how long is an Initial MTP good for? Its duration is good for 7 days beyond the expected MTP finalize date.

Decoding the Jargon Is there an easier way to see which MTPs or MTP Updates are soon to expire? Yes! Add and sort by the column “Date Effective Range” in patient lists.

Decoding the Jargon So what’s the connection between a MTP Update and the Care Plan? When a MTP Update is created, the current Care Plan is still included. When the MTP Update is formally finalized, a “snapshot” of the current Care Plan is “locked in” and the document cannot be edited.

Adding Medical Conditions What medical conditions should be included on the Initial MTP? All current medical conditions: A) Medical Issues nursing is actively monitoring and B) ongoing medical issues that are currently stable

Adding Medical Conditions to MTP Where can I add the medical conditions that should be included on the Initial MTP? Within the “Altered Health Status Due to” section of the Nursing note.

Adding Medical Conditions to MTP How can I add the medical conditions to be included on the Initial MTP? Select all body systems affected and replace the “***” placeholders with the specific name of the medical conditions.

Adding Medical Conditions to MTP What more is required for medical problems labeled as “stable? ” Within the same MTP note, select the provided Goals and Interventions for Stable Medical conditions. If no stable conditions, choose “NA” for Goals If no stable conditions, skip the last two interventions

Adding Medical Conditions to C. P. What more is required for medical problems NOT labeled as “stable? ” Nursing will construct the Problems, Goals, and Interventions for these conditions by making medical additions to the Care Plan

Adding Medical Conditions to C. P. Which conditions will ALWAYS require a medical addition to the Care Plan and cannot be labeled as “stable”? Ø Diabetes Ø High Fall Risk Ø Pain Ø Withdrawal Risk

Adding Medical Conditions to C. P How do nurses add the medical problems, goals, and interventions? Ø By adding each component individually, using the Care Planning Activity, which contains pre-made templates for several different medical conditions.

Adding Medical Conditions to C. P How do nurses add the medical problems? Use the templates provided or choose “*HBS New Problem” to manually type in your own.

Adding Medical Conditions to C. P. How do nurses add the medical Goals? Use the templates provided by searching by condition or choose “*HBS New LTG ” or “*HBS New STG ” to add your own.

Adding Medical Conditions to C. P. What needs to be added to Medical Goals? Add “Nursing” as the responsible discipline, add the Start Date and Expected End Date

Adding Medical Conditions to C. P. How do nurses add the medical interventions? Use the templates provided by searching by condition or choose “HBS new intervention” to add your own

Adding Medical Conditions to C. P. What needs to be added to Medical Interventions? Add [Your Name]as the responsible user, add the Frequency and clarification of designee.

Updating Medical Conditions in C. P. What needs to be updated in the Care Plan before MTP update is finalized? Change the goal’s start date and expected end date to match the dates of the MTP UPDATE. Also make a selection under This Visit’s Progress.

Other Considerations Are nurses expected to add goals or interventions to the psych problems listed in the Care Plan? Case Managers add behavioral health goals. Nurses add nursing interventions to the existing BH goals.

Other Considerations When are nurses expected to add nursing interventions to Psych Goals? After the CM has entered the Behavioral Health goals, but before the Initial MTP is signed (within the first three days of admission). the *Since many patients will not stay long enough to require an update, this is a small time window for BH nursing interventions to get on the Master Treatment Plan (which is signed by the patient, psychiatrist, the case manager, and the nurse)!

Other Considerations Do any interventions ever need to be added to long term goals? Interventions are not needed for Medical LTGs. However you will use the “intervention” section to add the phrase “Continue initial nursing care plan” or use intervention code 216.

Other Considerations Can medical problems listed in the Care Plan be resolved if no longer relevant? Yes

Other Considerations Should additional information ever be added later to the nursing note in the Initial MTP? Yes, but only in the brief period between admission and the Initial MTP being finalized. Do this by editing the note and manually typing an addendum at the bottom of the note as shown: