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A resident’s plan of care is like a road map. It provides instructions and directions on items that need to be completed in order for the resident to have improved health and positive outcomes.

Each resident has an individualized plan of care that is developed in collaboration with the resident, clinician, and physician. The goals included in the plan of care should be developed with input from the resident regarding his or her personal goals to be obtained during the SNF episode of care; the plan should include all orders for care and goals of care during the SNF care episode.

According to CMS, the content of the plan of care includes items such as...
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