Interprofessional Collaboration in Defensible Documentation

1. Purpose of Care Planning

This chapter will present the key concepts of care planning and the differences between the baseline care plan, the therapy plan of care, and the comprehensive interprofessional/interdisciplinary care plan. An overview of the federal requirements will be included. This information is important for SNF nurses and therapists to understand in order to ensure compliance with state and federal requirements of participation.

2. Creating Goals That Address Resident Goals

Goals for therapy and nursing should help to drive the plan of care to the destination the resident desires. This chapter will provide practical strategies for ensuring the resident’s goals are reflected adequately in the care plan and in specific enough terms to ensure the care team is on the same page and delivering effective care.

3. Interdisciplinary Management of the Care Plan

Today’s residents have complex health needs and typically require more than one discipline to address their health issues, but that doesn’t mean we work alone. This chapter will tackle the real-life conundrum facing all therapists and nurses in the SNF setting—how can we achieve truly collaborative care?—and provide learners with examples and resources to assist them in their journey to achieve an interprofessional team.