After reviewing the health records and conducting a patient visit including care planning, a comprehensive health assessment, and a medication management review, the student team will then write a draft of:
- Their overall assessment and recommendations, following the format used by the practice, such as SOAP or SBAR
- A patient care plan (for information on components, see Patient Encounter section)
The students will then present these to the patient’s care team and/or students’ preceptors, who will work with the student team to make any appropriate revisions. Inviting the patient and/or family/caregiver to the presentation is an option.
The practice team participating in the review meeting with the interprofessional student team should ideally include at least two relevant professions. This meeting should occur on another day following the patient visit, and may include presentations from other patient visits and/or other Clinical Interprofessional Curriculum (CIPC) activities.
Student presentations should follow a standard format, such as SBAR or SOAP. The written plan and presentation will incorporate findings from all care management activities. Following the student presentation, the final approved care plan is presented in writing to the patient and/or family/caregiver. The written individualized care plan is tailored to account for health literacy and language considerations.
Resources:
- Sample Care Plan (for preventing falls in hospitals)
- SBAR toolkit (Access to this toolkit requires registration with IHI, but it is free.)
- SBAR TeamSTEPPS
- SOAP Guidelines
Student Learning Objectives:
- Develop a review, assessment, and plan for a patient that includes comprehensive health assessment, a medication management review, and/or a care plan that includes a patient visit, which can be a home visit. The care management activities should: assist patients and their family/caregivers in managing their conditions; improve their health care; and reduce health costs.
- Develop and implement at least two health literacy skills from the AHRQ Health Literacy Universal Precautions Toolkit.
- Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services and programs. (IPEC VE5)
- Develop a trusting relationship with patients, families, and other team members (IPEC VE6)
- Engage diverse professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific health and healthcare needs of patients and populations. (IPEC RR3)
- Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
- Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
- Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
- Engage health and other professionals in shared patient-centered and population-focused problem-solving. (IPEC TT3)
- Integrate the knowledge and experience of other professions — appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
- Integrate the knowledge and experience of health and other professions to inform health and care decisions, while respecting patient and community values and priorities/preferences for care. (IPEC TT4)
- Reflect on individual and team performance for individual, as well as team, performance improvement. (IPEC TT8)