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Title: Section 758.4 - Interdisciplinary care planning

Effective Date


758.4 Interdisciplinary care planning. The operator shall ensure that: (a) each patient is assessed upon admission by the physician to determine appropriateness for admission, care to be rendered and services needed. The assessment shall include a physical examination, medical history, medication review, summary of treatment to date, assessment of current conditions and the patient's response to therapeutic interventions;

(b) an initial functional assessment of the patient is performed by the interdisciplinary team members within two weeks of admission; and

(c) a written comprehensive care plan for each patient, based upon initial and ongoing interdisciplinary assessments, which establishes rehabilitation goals and objectives, and which specifies which professional staff are responsible for care consistent with their scope of practice and expertise, including timeframes for accomplishment of goals, shall be developed and implemented. The care plan shall be reviewed at least every thirty days and modified by the team according to the patient's needs. The care plan shall address at a minimum the following areas: medical assessment, physical function, cognitive function, psychosocial function, independent living skills, vocational and educational information and discharge planning.


VOLUME E (Title 10)