Patient care plan

1. The general acute hospital shall ensure that a patient care plan is developed for each patient in coordination with the patient and appropriate health care personnel consistent with the licensed health care practitioner's orders. a. Initial assessment must begin upon admission and the patient care plan must be developed and implemented consistent with patient needs. The initial written patient care plan must be completed within twenty-four hours of admission and updated as needed. (1) Patient care plans must be kept current. Plans must address patient needs, including the methods and approaches to be implemented and modifications necessary to ensure that the patient attains or maintains the highest practicable level of functioning. (2) Patient care plan goals must be identified, measurable, and made known to all appropriate personnel. b. Progress notes must be reflective of the patient care plan and be informative and descriptive of the care given. The progress notes must include information and observations of significance which contribute to the continuity of patient care. c. Discharge planning must be initiated upon admission and kept current. (1) Appropriate discharge instructions must be provided to patients and family members dependent upon the patient's identified needs. (2) Patients, along with necessary medical information, must be transferred or referred to appropriate facilities, agencies, or outpatient services for followup or ancillary care as needed. 2. Primary care hospitals are subject to the patient care plan requirements for general acute hospitals in this section. 3. Specialized hospitals are subject to the patient care plan requirements for general acute hospitals in this section.