The Home Health nursing care plans and plan of care forms in this book cover every nursing diagnosis and care plan problem that may be generated from the OASIS form for the nursing plan of care. Terminology is based on OASIS language and nursing diagnosis definitions and classifications as outlined by the North American Nursing Diagnosis Association (NANDA).

The home health nursing care plan format follows the care plan standards from the American Nurses Association.

The first section of the book covers regulations and standards for nursing care plans, Home Health Nursing care plan components, and Quality Measures and Outcome Measures.

Because the terminology of the home health nursing care plan is based on OASIS language, it is very easy to see which care plans and plan of care forms are triggered by the OASIS entries.

The home health nursing care plans can be used to supplement the nursing plan of care, and are also extremely useful for teaching patients and caregivers.

All of the home health nursing care plans and nursing plan of care forms in the book are also on the CD. When the CD is placed in a computer, the care plans can be opened in a word processor. Entries can be added or deleted to individualize home health nursing care plans.

Home Health Nursing Care Plan Standards and Regulations

Excerpts from OASIS Guidance Manual, Appendix A, Centers for Medicare & Medicaid Services:

The comprehensive assessment must

(1) identify the patient’s continuing need for home care;

(2) meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs; and

(3) for Medicare patients, identify eligibility for the home health benefit, including the patient’s home-bound status.

It should be noted that the data items in OASIS are not, in and of themselves, a complete or comprehensive assessment. Home health agencies will need to supplement the OASIS data items with others necessary for a full assessment.

For example, the OASIS items do not include vital signs, assessment of breath sounds, or collection of data on fluid intake, which are part of a more complete assessment. Each agency will be expected to incorporate the OASIS items into its own comprehensive assessment documentation and related policies and procedures.

The Home Health Nursing care plan is the blueprint for the patient’s entire care needs, and directs the actions of all health care team members. A new caregiver should be able to know everything essential about the patient by reading the Home Health Nursing care plan.

The Home Health Nursing care plan is a measure of quality of care. It gives a comprehensive picture of where the patient is at present and what is hoped to be achieved in the future, and is a guide for daily charting and care.

The Home Health Nursing care plan:

Increases consistency of care

Focuses all interdisciplinary team members on the same problems

Describes the patient’s functional abilities and needs

Sets goals to maintain the patient’s highest level of functioning

Addresses the patient’s physical, mental, emotional, and social needs

Provides a reference to measure progress or decline in the patient’s condition.

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