Knowledge Base Article: Completing the Initial Comprehensive Plan of Care (POC)

Overview

This article guides you through the process of reviewing, finalizing, and signing the Initial Comprehensive Plan of Care (POC) within Hospice Works. It ensures all regulatory 5-day admission requirements are met before routing the document to the interdisciplinary group (IDG) for electronic signatures to document their review, participation and agreement. The attending physician electronically signs to approve the plan of care.

Prerequisites & Dashboard Tracking

When a new patient is admitted, Hospice Works automatically generates a compliance checklist on the patient’s Care Management dashboard.

  • Day 1 Admission Tasks: Items like the Initial Nursing Assessment, Verbal Certifications, and Initial Physician Orders are automatically checked off by the system as they are completed.

  • 5-Day Admission Requirements: These include the Hospice Outcomes and Patient Evaluation (HOPE) Admission, Initial Psychosocial Assessment, and the Initial Spiritual Assessment.

    Note: If a service is offered and declined (e.g., Spiritual Assessment), it will be marked accordingly on the dashboard to maintain compliance.

Step-by-Step Instructions

Step 1: Access the Comprehensive Plan of Care

  1. Navigate to the patient's dashboard.

  2. Under the 5-Day Admission Requirements section, click the link titled Complete Comprehensive Plan of Care.

  3. On the Interdisciplinary Group and Comprehensive Plan of Care page, locate the current in-progress plan and click View.

Step 2: Review Auto-Populated Plan Data

The system automatically compiles and populates data from the patient’s initial assessments. Scroll through the document to review:

  • Patient Demographics and Terminal/Co-morbid Diagnoses.

  • POC Summary: Living arrangements, advance directives, and emergency triage levels.

  • Care Plans: Active goals and interventions (e.g., Anxiety, Incontinence, Pain Management).

  • Medication Profile & DME: Current medications, medical equipment (DME), and medical supplies.

Step 3: Resolve Document Requirements (System Flags)

If you scroll to the bottom of the POC and see a Document Requirement Not Met banner, the system will temporarily lock the signing feature.

  1. Review the flagged requirement text (e.g., "The following requirement must be completed before signing: Complete Psychosocial Assessment").

  2. Return to the patient dashboard to complete or log the missing assessment.

  3. Once the dashboard reflects that the pending assessment is Completed, click back into the Complete Comprehensive Plan of Care link and select View. The system flag will now be removed.

Step 4: Route for Electronic Signatures

The Registered Nurse (RN) is responsible for initiating the signature routing process.

  1. Scroll to the Team section at the bottom of the POC to verify the care team members.

  2. Click the green Ready to Sign button.

  3. On the Signatures page, review the attestation statement and click Sign.

  4. A Signature Confirmation pop-up will appear. Click Confirm to apply your electronic signature.

Post-Signature Workflow

Once the RN signs the document, Hospice Works automatically routes the Initial Comprehensive POC to the following team members for their respective signatures:

  • Attending Physician

  • Social Worker

  • Chaplain

(Note: Disciplines that were declined during admission, such as the Chaplain in the companion video example, are excluded from the required routing path).

Need Support?

If you encounter any system blocks or have questions regarding patient dashboards, please contact the support team at support@hospiceworks.com.