Plan of Care, Part 3 - Michigan



Plan of Care, Part 3Michigan Department of Health and Human ServicesMaternal Infant Health ProgramBeneficiary FORMTEXT ?????Case ManagerReassigned Case ManagerReassigned Case Manager FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????We, the undersigned, have reviewed the risk identifier, participated in case consultation and have assisted in development of the plan of care. We concur with the approach to case management and implementation of the interventions.INITIAL PLAN OF CARERegistered Nurse Signature/CredentialsDate FORMTEXT ????? FORMTEXT ?????Licensed Social Worker Signature/CredentialsDate FORMTEXT ????? FORMTEXT ?????Other Disciplines Contributing to POC (Registered Dietitian/Infant Mental Health Specialist/IBCLC Lactation Consultant)Date FORMTEXT ????? FORMTEXT ?????CARE PLAN REVISIONSDomain FORMTEXT ?????Registered Nurse Signature/CredentialsDate FORMTEXT ????? FORMTEXT ?????Licensed Social Worker Signature/CredentialsDate FORMTEXT ????? FORMTEXT ?????Other Disciplines Contributing to POC (Registered Dietitian/Infant Mental Health Specialist/IBCLC Lactation Consultant)Date FORMTEXT ????? FORMTEXT ?????Domain FORMTEXT ?????Registered Nurse Signature/CredentialsDate FORMTEXT ????? FORMTEXT ?????Licensed Social Worker Signature/CredentialsDate FORMTEXT ????? FORMTEXT ?????Other Disciplines Contributing to POC (Registered Dietitian/Infant Mental Health Specialist/IBCLC Lactation Consultant)Date FORMTEXT ????? FORMTEXT ?????The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.Plan of Care, Part 3 INSTRUCTIONSThese instructions are intended to clarify data fields. If you have additional questions, please contact the MDHHS MIHP Team.Initial Plan of Care 2The top section documents that the two required disciplines (at a minimum) have developed, reviewed and concur with the beneficiary’s initial POC 2. The nurse and social worker do not sign the POC 3 until they have reviewed the electronic Risk Identifier in its entirety and pulled the appropriate risk domains to compile the beneficiary’s POC 2.When entering dates, use the preferred format: MM/DD/YYYY.Beneficiary: Insert beneficiary’s first and last name.Case Manager: Insert the first and last name of the case manager (RN or SW); credentials are not required.Reassigned Case Manager: If the case manager changes during the course of care, insert the new case manager’s first and last name; credential are not required.Registered Nurse Signature/Credentials: Sign first and last name and credential. Include license in credentials (RN). Signature must be dated within 10 business days of licensed social worker’s signature.Date: Insert date of signature.Social Worker Signature/Credentials: Sign first and last name and credentials. Include license in credential (LLBSW, LLMSW, LBSW, or LMSW). Signature must be dated within 10 business days of registered nurse’s signature.Other Disciplines Contribution to POC: The Registered Dietitian (RD), Infant Mental Health Specialist (IMHS), or IBCLC Lactation Consultant signs and dates here if they participated in development of the original POC 2.Care Plan RevisionsTwo additional sections document that a risk domain has been added to the POC 2 because the beneficiary’s situation matches the risk criteria in Column 2 of the POC 2.Domain: Insert the title of the risk domain that has been added to the POC 2.Registered Nurse Signature/Credentials: Sign first and last name and credential. Include license in credentials (RN). Signature must be dated within 10 business days of licensed social worker’s signature.Date: Insert date of signature.Social Worker Signature/Credentials: Sign first and last name and credentials. Include license in credential (LLBSW, LLMSW, LBSW, or LMSW). Signature must be dated within 10 business days of registered nurse’s signature.Other Disciplines Contribution to POC: The Registered Dietitian (RD), Infant Mental Health Specialist (IMHS), or IBCLC Lactation Consultant participates in the decision to add a domain to the POC 2, they sign here and enter the date.If Agency is Missing a DisciplineBeneath the signature line, write: Agency is without SW (or RN) or in process of hire or other language that indicates the agency is devoid of one discipline at the time the POC 2 was developed.When the replacement SW or RN is hired, he or she should review and sign the POC 3 on or near the signature line with the current date, indicating concurrence with the POC 2. ................
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