Clinical Diagnostics

CLINICAL & DIAGNOSTICS INFORMATION

Policy 2: Holy Trinity Center director of nursing shall ensure that plan of care is developed for each individual served; specific to the medical necessity and severity of needs of the individual served that is supervised or completed by the registered nurse.

Procedures 2: Holy Trinity Center’s registered nurse as stipulated in the policy 2 above shall also ensure that all the needed tasks, duties, responsibilities, and training is provided as:

1. a) An individual’s plan of care shall be based on assessments of the client’s health, function, and psychosocial condition performed by a registered nurse.
2. b) An assessment of an individual served shall be completed when the individual is requesting or requiring services regulated by this chapter;
3. c) An assessment of an individual served shall be completed before the individual receives services from the agency unless.
4. The client does not request skilled care or skilled services; and
5. There is no reason to believe that the individual requires skilled care or skilled services, such as discharge instructions requiring skilled care;
6. d) An assessment of an individual served shall be completed within 48 hours of when the individual begins services; when the individual requires, including but not limited to:

(i) Wound and catheter care;

(ii) Treatment of stage three or stage four skin ulcers;

(iii) Ventilator services;

(iv) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition;

(v) Monitoring of a chronic medical condition that is not readily controllable through available medications and treatments;

(vi) Infusion therapy;

(vii) Specialized intravenous therapies or nutrition support;

(viii) Monitoring for being at high risk for health or safety complications which cannot be adequately managed; or

(ix) A different level of care after notification of a significant change of condition;

1. e) An assessment of an individual served shall be completed at the request of the individual or the individual’s representative;