Plan of care builder
A plan of care is a promise with numbers in it: this many visits, over this long, to reach these measurements. Payers certify plans; they do not certify intentions.
Visits authorised by this plan
12
2× a week for 6 weeks. A payer reads frequency and duration together — one without the other is an incomplete plan.
A goal without a number is a wish
The test for a goal is whether two clinicians reading the chart in eight weeks would agree that it was met. “Improve tolerance to sitting” fails. “Sit 45 minutes at the desk without pain rising above 3/10, by week 4” passes: the activity, the threshold and the date are all in it.
Frequency without duration
“2–3× per week as needed” is the plan most often kicked back. It has no end, so it cannot be certified and cannot be measured against. Pick a number of weeks; you can always re-certify.
The plan is the spine of the whole episode
Every daily note refers to it, the progress note measures against it, and the discharge summary closes it. If the daily notes describe interventions the plan never named, or the visit count drifts past the certified duration, the mismatch is what a reviewer finds first — before they read a single clinical sentence.
Re-certify rather than drift
Patients change. A plan that no longer fits should be re-written and re-certified, with a re-examination behind it, rather than quietly extended. That is the difference between a re-evaluation and a progress note, and it is covered in the evaluation code guide.
Red flag — refer out
A plan that is not working is information. When goals stall with no explanation, or the picture worsens against a reasonable plan, the next step is a referral, not another six weeks.
Sources
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