Overview: HospiceWorks now lets clinicians document a quick, measurable Progress/Outcome for Care Plan Goals & Interventions during visit charting (optional). The latest selection automatically updates Care Plan History and auto-populates into IDG/IDT, reducing rework and supporting consistent plan-of-care review. A Reason is only required when “Not Addressed” is selected. 


Applies to: Nurse Visit Note → Care Plans → Goals & Interventions
Audience: Clinicians (RN/LVN/LPN), Clinical Supervisors, IDG/IDT participants
Purpose: Quick, measurable care plan documentation that automatically stays current in Care Plan History and IDG/IDT.

Care Plan Documentation

HospiceWorks includes a Progress/Outcome dropdown for Care Plan Goals & Interventions (when documentation is enabled). Options include:

  • Improving

  • Stable

  • Worsening

  • Not Addressed

This is designed to be fast, optional, and measurable.

Why This Matters

When you document Progress/Outcome during a visit, HospiceWorks automatically:

  1. Updates Care Plan History with the latest Progress/Outcome

  2. Auto-populates IDG/IDT with the latest Progress/Outcome

So your team can see current status quickly—without searching through prior notes or doing last-minute IDG/IDT cleanup.

Where to Find It

  1. Open the Nurse Visit Note

  2. Go to the patient’s active Care Plans

  3. In the Goals/Interventions table, use the Progress/Outcome column (when available)

How to Use It (Simple Workflow)

  1. Identify the Goal or Intervention you addressed during the visit

  2. (Optional) Select a Progress/Outcome

  3. Add Notes if needed (optional)

  4. Save the visit note

- Best practice: Only document Progress/Outcome when it adds clinical value.
- No pressure: Leaving it blank is acceptable when you didn’t address that item.

Choosing the Right Progress/Outcome

Improving

Use when the patient shows measurable/observable improvement related to that goal or intervention.

Examples:

  • Less pain episodes / improved comfort

  • Fewer breakthrough symptoms

  • Improved tolerance of activity

Stable

Use when there is no meaningful change—symptoms/response remain controlled or unchanged.

Examples:

  • Pain controlled on current regimen

  • Dyspnea unchanged with current supports

Worsening

Use when symptoms or decline indicators have increased related to that goal/intervention.

Best practice: Add a short note about what changed and what action was taken.

Examples:

  • Increased pain, increased PRN use

  • New or increased dyspnea

  • Decline in function or intake

Not Addressed

Use only when the goal/intervention was intentionally not addressed during the visit.

Examples:

  • Patient declined

  • Patient asleep / unavailable

  • Not clinically indicated this visit

  • Visit focus shifted due to urgent need

Important Rule: “Not Addressed” Requires a Reason

If you select Not Addressed, HospiceWorks will require a Reason to document why it wasn’t addressed.

  • Progress/Outcome blank → no Reason required

  • Progress/Outcome = Not Addressed → Reason required

This keeps documentation clear without forcing care plan charting on every item.

Completed Toggle Behavior (Keep It Simple)

When the clinician marks a Goal/Intervention Completed:

  • Progress/Outcome is disabled

  • Reason is available (optional)

  • Notes remain available (optional)

This prevents conflicting documentation and keeps the workflow clean.

Medication Interventions in Care Plans

Medication “completion” is typically handled by physician orders (e.g., discontinue/change order), not by a Completed toggle inside the care plan row.

Recommended workflow:

  • Document medication administration/effectiveness in Medication Management / MAR

  • Use Progress/Outcome primarily for goals and non-medication interventions

(Your agency may choose to keep medication rows read-only in care plans to avoid duplication.)

What Automatically Updates (No Extra Steps)

Care Plan History

  • The latest Progress/Outcome selection is stored so trends are easy to see.

IDG/IDT

  • The latest Progress/Outcome auto-populates so the team can quickly identify:

    • What’s improving

    • What’s stable

    • What’s worsening

    • What wasn’t addressed (and why)

Quick Examples

Example 1 (Improving)

Goal: Pain controlled with current regimen

  • Progress/Outcome: Improving

  • Notes (optional): “Pain 3/10 today; fewer PRN doses needed.”

Example 2 (Stable)

Intervention: Education on positioning for dyspnea

  • Progress/Outcome: Stable

  • Notes (optional): “Continues positioning; no change from baseline.”

Example 3 (Worsening)

Goal: Anxiety maintained at baseline

  • Progress/Outcome: Worsening

  • Notes (recommended): “Increased restlessness; MD notified; new order requested.”

Example 4 (Not Addressed)

Intervention: Home safety education

  • Progress/Outcome: Not Addressed

  • Reason: “Patient declined”

  • Notes (optional): “Will review next visit.”

FAQ

1. Do I have to complete Progress/Outcome for every care plan item?
No. It’s optional. Leave it blank when you did not address that goal/intervention.


2. Where do I see what I documented later?
The latest Progress/Outcome is visible in Care Plan History and IDG/IDT automatically.


3. What if I select Not Addressed?
A Reason is required so the record clearly explains why it wasn’t addressed.


4. Do I need to duplicate medication effectiveness here?
Typically no—use MAR/Medication Management for administration and effectiveness.