Step A1: Assessment
1. Obtain and review information including:
Personal and medical history including physical, functional, psychosocial information
Past medical history and physical, diagnostic tests, laboratory results, practitioner orders, medications
2. Observe patient/resident.
3. Conduct physical assessment including review of systems, functional, cognitive and other specialty assessments.
Step A2: Problem Identification/Diagnosis
Problem Identification/Diagnosis – What is the problem?
1. Use clinical judgment to interpret and analyze data.
2. Identify how existing symptoms, signs, diagnoses, test results, dysfunctions, impairments, disabilities, and other findings relate to one another.
3. Identify the need for additional analysis and intervention
4. Define significant risk factors.
Taken together, these first two steps enable the clinician to develop pertinent, individualized care plans and interventions.
Step B: Care planning
How to manage the identified problems
1. Define overall goals and objectives for services and care with the individual.
2. Set priorities.
3. Identify risks and benefits of treatment options.
4. Select appropriate interventions.
5. Clarify prognosis.
6. Write plan of care.
Step C: Intervention and Monitoring
Putting the plan into action
1. Utilize the care plan to coordinate and provide care for the individual.
2. Identify and implement interventions and treatments to address the individual's physical, functional and psychosocial needs, concerns, problems and risks.
3. Administer treatments and services.
4. Monitor condition and response to treatment and interventions.
5. Manage complex situations and complications.
Step D: Evaluation
Did the plan work?
1. Evaluate the effectiveness of the interventions and the appropriateness of the care plan.
2. Identify course of condition, success of interventions and progress toward goals.
3. Identify factors that are affecting progress towards achieving goals.
4. Adjust treatments and interventions based upon individual’s response.
5. Continue to implement and evaluate care plan.
6. Reassess and identify when care objectives have been achieved sufficiently to allow for discharge, transfer, or change in level of care