Q:
After completing my baseline care plan, what should I include in my summary to be provided to the resident/representative?
A:
The facility must provide residents and their representatives, if applicable, with a written summary of the baseline care plan prior to the completion of the comprehensive care plan. This summary must include initial goals, a list of current medications and dietary instructions, and details about services and treatments to be administered. The summary must be provided in a language and manner that the resident/representative can understand. Current medications may be provided by including a copy of the MAR, for example, but may not be easily understood if medical terminology and abbreviations are used.
The format and location of the summary are at the facility’s discretion, but the medical record must show evidence of providing the summary to the resident and representative. The facility may opt to provide a copy of the baseline care plan itself as long as it meets the summary requirements.
As the baseline care plan is developed before the comprehensive assessment, any changes in goals or interventions identified during the comprehensive assessment must be incorporated into an updated summary for the resident and representative, if applicable.
Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant
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