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 Target / dry weight: ______ lb. Weight-change report threshold: ______ lb over ______ day(s). Blood-pressure range: ______ to ______; heart-rate range: ______ to ______. Daily fluid limit: ______ mL; sodium limit: ______ mg/day. PRN diuretic parameter (if ordered): ______. Activity and oxygen orders: ______. |
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Plan-of-care goal templates
Edit each goal to the patient's ordered values and target dates.
- Patient will maintain weight within ______ lb of the ordered dry weight (______ lb), verbalizing daily-weight monitoring and the report threshold, by [date].
- Patient and caregiver will demonstrate the heart-failure action plan (green / yellow / red zones) with teach-back ≥ 90% by [date].
- Patient will remain free of avoidable acute-care use for heart-failure decompensation through the certification period.
- Patient will adhere to the ordered sodium and fluid limits and the guideline-directed medication regimen, verbalizing purpose and adverse effects, by [date].