Behind the patient's care door on the care-team dashboard (the door named after the patient, Debbie's care), right after the patient's Schedule, is Home Care Team Plan: the plan's home, with how many of the 25 sections are complete and the 25 sections as a list. Tap a section and it opens on its own page, with only that section on it: All sections at the top, the section's fields, Previous section and Next section at the bottom. Every field saves itself as you type, the same way the family's own plan does.
The tab is there for a nurse, a physician (MD, DO, NP or PA), a speech, physical or occupational therapist, a chiropractor, hospice or palliative care and a community paramedic who joined the family's Care Team with the family's code. A home health aide, a case manager and the agency office do not have it, and a member of an organization who opened the patient from the organization panel fills the plan in from there instead (Starting a care plan for a patient).
One line at the top of the plan and of every section says which of two things applies. You can fill this in directly: the family turned on Can fill in the Home Care Team Plan directly on your card under Doctors, nurses & clinics, so every field you fill saves at once in the patient's plan and reads with your name and discipline, for example Nora Sample (Nurse); each field shows Saved. What you enter goes to the family to accept: the switch is off (it starts off), so each field reads Proposed, the section comes to the family on their Care team page, under Organizations for the patient's care, labelled with your name and discipline, with Accept and Decline, and nothing in the patient's plan changes until they accept. While a proposal waits you see your proposed values in the fields, marked Proposed to the family, and later fields of the same section join the same proposal, so the family answers one proposal per section. Once the family accepts, the values are in the plan, stamped with your name and accepted by the family member who answered.
Values the family keeps on their own pages, the Patient Profile, the Emergency Plan Card, Prescriptions and Menu & Kitchen, are shown in the plan but change only there; those fields read The family changes this. The Weekly Coverage Plan, the Care Hours, the Team Roster and the readiness statements are read from the family's records the same way the family sees them.
The family can turn the switch on or off at any time on your card; the line at the top of the plan says which applies the next time you open it. The plan is the family's working copy; it does not replace a doctor's orders or a licensed professional's plan of care.
Step by step
- 1On the care-team dashboard, tap the patient's care door (Debbie's care), then Home Care Team Plan, and read the line at the top: You can fill this in directly, or What you enter goes to the family to accept.
- 2Tap a section, for example 2. Person Centered Preferences, to open it on its own page.
- 3Fill in a field, for example the usual wake time, and read Saved beside it (direct) or Proposed (it went to the family).
- 4Tap Next section to go on, or All sections to go back to the list; the dashboard's tab shows the same list.
- 5When a proposal waits, the field reads Proposed to the family until the family accepts or declines it on their Care team page.