Q&A: Clarifying PC.01.03.01 EP 1 (Nursing care planning)

Q: The surveyor found that on three records, there was lack of pertinent patient problems cited on an initial nursing assessment and lack of documentation on the interdisciplinary plan of care to address individual patient issues. Can I clarify this finding?

A: What you would consider in this case for a clarification is:

• What is your policy on care planning?
• When was the care plan generated as opposed to when the surveyor reviewed it? (For example, was there time to develop a comprehensive care plan?)

From a nursing process perspective, was what was documented on the care plan sufficient to address the real patient problem? Can you conduct an audit of all records requiring an initial nursing assessment and care plan to demonstrate that you can meet the 90% compliance requirement? You probably have a good chance to clarify this citation if you typically have a solid care planning process.

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