Question

Name 5 things a surveyor may look for in your care plan documentation.

a) Doctor's signature, patient's favorite color, employee ID number, cafeteria menu, weather forecast
b) Patient's name, date and time of care, medication dosage, patient goals, progress notes
c) The hospital's mission statement, employee parking assignments, gift shop sales data, social media posts, cafeteria hours
d) Employee's shoe size, patient's pet preference, preferred holiday destination, nursing shift schedules, nurse's favorite song

Answer 1

Surveyors would look for details such as the patient's name, date and time of care, medication dosage, patient goals, and progress notes in care plan documentation to ensure a comprehensive and accurate plan for patient care.

Step-by-step explanation:

A surveyor looking at your care plan documentation would likely be interested in finding the following information:

• Patient's name, to ensure the care plan is correctly linked to the individual receiving care.
• Date and time of care, to track when the patient received specific treatments or interventions.
• Medication dosage, to verify that the patient is receiving the appropriate amount of medication as per their treatment plan.
• Patient goals, to understand what the care plan intends to achieve in terms of the patient's health outcomes.
• Progress notes, to monitor how well the patient is progressing towards those goals and to make any necessary adjustments to the care plan.

These elements are critical to ensure that health records reflect an accurate and comprehensive plan for patient care, aligned with both medical best practices and individual patient needs. They also help maintain a standard of care that includes crucial aspects such as medication management, patient-safety, and goal setting. Notably, the information must be detailed and up-to-date, reflecting any changes in the patient's condition or treatment protocol.