2. Plan-of-care goals — provider parameters govern
The patient-specific, provider-ordered parameters always control. Record them first; the goals that follow are completed with the patient's actual ordered values, and every threshold elsewhere in this overlay defers to these orders.
▶ Provider-ordered parameters — record before charting goals Anticoagulant and indication: ______ (warfarin / apixaban / rivaroxaban / dabigatran / edoxaban) for ______ (atrial fibrillation / venous thromboembolism / mechanical valve). Target INR range (warfarin): ______ to ______. INR-monitoring schedule (warfarin): ______; renal-function monitoring schedule (DOAC): ______. Bleeding-precaution parameters and what to report: ______. Hold or reversal orders and parameters: ______. |
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Plan-of-care goal templates
Edit each goal to the patient's ordered values and target dates.
- Patient will maintain INR within the ordered range (______ to ______) if on warfarin, verbalizing the monitoring schedule and bleeding precautions, by [date].
- Patient and caregiver will demonstrate bleeding-precaution practices and warning-sign recognition with teach-back ≥ 90% by [date].
- Patient will adhere to the anticoagulant regimen and avoid interacting medications and foods, verbalizing the plan, by [date].
- Patient will remain free of major bleeding and thromboembolic events through the certification period.