5.25 – Nursing Care Plan (ICF)
Upon admission, the nursing staff will be responsible or evaluating and assessing the individual thoroughly in order to:
- Complete physical body systems assessment by admitting nurse
- Initiate Nursing Care plan within 72 hours of admission
- Implement physician orders including obtaining proper medication clarifications, communication with pharmacy regarding needs, and ensuring all orders are initiated
- Communicate with Medical Director
- A complete History and Physical must be completed by the Medical Director within 30 days of admission.
The Medical Plan of Care, with direction of Medical Director, shall be reviewed and updated for:
- Scheduled admission to hospital
- Return from hospital
- Prior to and after diagnostic and/or therapeutic procedures
- Transfer to another residential alternative
- ANY major change in physical condition or nursing care occurs
- On a quarterly basis when physical assessment changes are indicated
All Care plans, with direction of Medical Director, must be updated at least annually for all individuals, if none of the above apply.
Last Revised: 6/8/21