Care Goals & Decision Making
Care Goals & Decision Making are elements of the Care Management Determinants that are that can decisively affect patient well-being and patient recovery. Care Goals include a listing of symptoms (S Codes) and determinants (D Determinants) that the Care Plan is developed to improve.
Contents
Diagnosis Codes
These are listing of impactable Physical Conditions and Mental Health Conditions determinants (D Codes) that the patient and providers are trying to improve with the Care Plan. These are found in the patient's Medical Record.
Physical and Mental Health Biomarkers
These are listing of impactable Physical Conditions and Mental Health Conditions determinants (D Codes) that the patient and providers are trying to improve with the Care Plan. These biomarkers are typically found in the patient's Medical Record in support of the diagnosis codes.
- Blood Pressure, HbA1C blood test, cholesterol, etc.
- Depression, Anxiety, etc.
Symptoms
These are listing of the patient provided symptoms that the patient and providers are trying to improve with the Care Plan. These are provided by the patient via the Patient Well-Being Assessment or the Patient Well-Being Status.
Functional Limitations
These are listing of the patient provided Functional Limitations that the patient and providers are trying to improve with the Care Plan. These are provided by the patient via the Patient Well-Being Assessment or the Patient Well-Being Status.
Quality of Life Limitations
These are listing of the patient provided Quality of Life Limitations that the patient and providers are trying to improve with the Care Plan. These are provided by the patient via the Patient Well-Being Assessment or the Patient Well-Being Status.
- Activities
- Socioeconomic
- Purpose
- Competence
- Connections
Preferences
- Treatment Preferences - Home Based, Recovery Team, Technology Use, Palliative Care and End of Life preferences
- Authorizations - Privacy and HIPAA, Advanced Beneficiary Notice, Recovery Team Access to Electronic Medical Records
- Living Will - Advanced Patient Directives
