The successful transition of care at discharge depends enormously on the involvement of the patient and family. Outcomes are greatly improved when the patient understands the goals of post-discharge care, and is involved in decisions about achieving those goals. The multidisciplinary care plan lists the goals of discharge treatment(s) for this hospital visit, along with the instructions or interventions planned to achieve each goal.
The Care Plan can be viewed by all clinicians who write discharge orders or instructions.
Each goal includes the name of the clinician who last entered or updated it, the date and time, and which discharge folder it's from.
This information is included in the post-hospital patient care plan (PHPCP), which
To update the list, open the Order Info folder by clicking the folder.