Wis. Admin. Code Department of Health Services DHS 133.20 - Plan of care
(1) REQUIREMENT. A plan of care, including
physician's, advanced practice nurse prescriber's, or physician assistant's
orders, shall be established for every patient accepted for care and shall be
incorporated in the patient's medical record. An initial plan shall be
developed within 72 hours of acceptance. The total plan of care shall be
developed in consultation with the patient, home health agency staff,
contractual providers, and the patient's physician, advanced practice nurse
prescriber, or physician assistant and shall be signed and dated by the
physician, advanced practice nurse prescriber, or physician assistant within 20
working days following the patient's admission for care.
(2) CONTENTS OF PLAN. Each plan developed
under sub. (1) shall include:
(a) Measurable
time-specific goals, with benchmark dates for review; and
(b) The methods for delivering needed care,
and an indication of which professional disciplines are responsible for
delivering the care.
(3)
REVIEW OF PLAN. The total plan of care shall be reviewed by the attending
physician, advanced practice nurse prescriber, or physician assistant, and
appropriate agency personnel as often as required by the patient's condition,
but no less often than every 60 days. The agency shall promptly notify the
physician, the advanced practice nurse prescriber, or the physician assistant
of any changes in the patient's condition that suggest a need to modify the
plan of care.
(4) ORDERS. Drugs and
treatment shall be administered by the agency staff only as ordered by the
attending physician, advanced practice nurse prescriber, or physician
assistant. The nurse or therapist shall immediately record and sign and date
oral orders and obtain the physician's, the advanced practice nurse
prescriber's or physician assistant's countersignature and date within 20
working days.
Notes
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