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Treatment Plan Reports

Printed Page 275

The ability to communicate information about patients or clients is important for all health care providers. Either individually or as part of a health care team, people in the helping professions often report patients’ conditions and outline plans of treatment to other health care providers. One form of treatment plan report, called the case conference, includes the following:

Description of patient status
Explanation of the disease process
Steps in the treatment regimen
Goals for patient and family
Plans for patient’s care at home
Review of financial needs
Assessment of resources available

The shift report is a concise overview of the patient’s status and needs, delivered to the oncoming caregiver. It includes the following information:

Patient name, location, and reason for care
Current physical status
Day on clinical pathway for particular diagnosis
Pertinent psychosocial data, including plans for discharge and involvement of caregivers
Care needs (physical, hygiene, activity, medication, nutritional)