This is a quality measure at the VA, a plan of care note must be completed for every single patient at least once per year. Typically, this is completed during the patient visit, printed and handed to the patient when they leave so that they have a summary of what occurred during the visit. I also recommend making these for acute visits when many medication changes are made or if many consults are placed so that the patient is aware of the plan. This cuts down on confusion for the patient, phone calls to your clinic and increases the patient’s satisfaction when they are aware of the treatment plan.
This is how to make the note:
1. Make a new note entitled PACT PLAN OF CARE NOTE (Notes tab ->New Note)
2. I do not recommend using the click through template provided in the pact plan of care note template because it is burdensome to use, instead click OK when the dialogue box comes up. This will then leave you with an open note that is blank where you can insert your own template – the person training you will assist you with making a template for your clinic
a. I recommend including your clinic information and common phone numbers including the phone numbers to the pharmacy, veteran’s crisis line, audiology and the eye clinic automatically for the patient’s reference
3. Complete the note as you see fit (address any medication changes or consults placed, I often address that the patient must complete x-rays before seeing orthopedics or podiatry and must complete a urine drug screen before seeing the pain clinic so that they are aware that they must take action prior to these consults being placed, I also place instructions for how to complete FIT testing in these notes when indicated). I also address when follow-up is due and to complete labs at least 3 days prior to make for a fruitful follow up visit.
4. Sign and print and provide to the patient
If you are unable to provide the pact plan of care during the visit or would like to mail the patient a new pact plan of care if the plan has changed you can complete a plan of care with the directions above then open a “Test results notification” letter, copy and paste the plan of care into that note and it will automatically be mailed to the patient when you sign it in CPRS.