questionnaire to develop an educated plan of care to determine the needs and

Questionnaire to develop an educated plan of care to

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questionnaire to develop an educated plan of care to determine the needs and goals for the patient . During the Intake Process The CM obtains all the information required during the process such as patients medical history, height /weight, medication list, surgery history, medication compliance, what kind of help is needed at home (i.e. ADL care). The CM has pre-screened the patient for HEDIS alerts an the CM briefly discusses these alerts and asks patient if the cancer screenings have been done, what is being done about her weight, does she manage her diabetes indepdentley with medications, and check her blood sugar, last eye exam and if medication adherence is being done with her statin med. The CM will discuss goals and concerns that the patient may have to develop a patient-approved plan of care. Once Admitted to the Program The Case Manager will develop the plan of care once all the data has been collected, the electronic medical record is updated with this confirmed information so everyone accessing the record will have the same available knowledge. The CM monitors the patient for a 30 day period. Throughout the 30 days, the CM educates the patient on the HEDIS alerts. The patient is sent education information in the form of educational videos via email. The CM reaches out to the patient within 30 days, and if the HEDIS alerts have been addressed, the CM clears them out of the system and noted as completed. “Nursing Informatics is a subset of informatics, specific to the field and the role of the nurse in the healthcare setting” Sweeney, 2017).
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  • Fall '16
  • Cheryl Wagner
  • Nursing

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