105 CMR, § 143.010 - Treatment Planning

(A) A written treatment plan based on subjective and objective evaluations as documented in the patient record shall be developed for each patient by a multidisciplinary team of staff involved in the patient's care including the registered nurse and medical director.

(B) The treatment plan shall include a problem list and established patient goals that are based on the individual patient's risk factor profile, functional capacity, potential for improvement and the patient's personal goals.

(C) The written plan to achieve goals shall include the specific intervention for each risk factor, and specific exercise prescription based on recent symptom-limited exercise tolerance test.

(D) Treatment plans shall be reevaluated as necessary but at least prior to advancement to Phase III.

(E) Upon completion of the Phase III Cardiac Rehabilitation component, a discharge evaluation of the patient shall be made by the nurse and/or program coordinator with the participation of the patient. The discharge evaluation shall be based on subjective and objective measurements, as documented in the patient's record. to identify progress towards goals and to establish ongoing maintenance goals.

Notes

105 CMR, § 143.010