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Care Plan 2.0: Assessments, Social Determinants of Health (SDOH) & Vitals

Module: Care Plan 2.0

Written by HealthArc Support

Overview

The Assessments, Social Determinants of Health (SDOH), and Vitals sections provide a comprehensive view of the patient's clinical condition and the non-clinical factors that may influence their health outcomes.

These sections enable care teams to document standardized patient assessments, identify barriers to care, evaluate social and environmental factors, and monitor physiological measurements. Together, they help create personalized, evidence-based care plans and support ongoing patient management.


Before You Begin

Before completing these sections, ensure that:

  • A Care Plan has been created.

  • The patient's demographic information has been reviewed.

  • Recent clinical information is available.

  • Assessment questionnaires, if applicable, have been completed or are ready to be administered.


Navigation

  1. Log in to the HealthArc Portal.

  2. Navigate to Patients.

  3. Select the patient.

  4. Open the Care Plan tab.

  5. Open the draft Care Plan.

  6. Complete the following sections:

    • Assessments

    • Barriers to Care

    • Social Determinants of Health (SDOH)

    • Vitals


Assessments

Overview

The Assessments section allows care coordinators to administer standardized clinical questionnaires that help evaluate the patient's physical, behavioral, and functional health.

Assessments provide objective information that supports clinical decision-making and helps identify areas requiring intervention.

Depending on your organization's configuration, multiple assessment types may be available.

Care Plan 2.0 allows assessments to be:

  • Completed during the patient encounter

  • Sent electronically to the patient

  • Reviewed after submission

  • Stored as part of the patient's Care Plan history


Sending an Assessment to a Patient

If an assessment can be completed independently by the patient:

  1. Open the Assessments section.

  2. Select the desired assessment.

  3. Choose Send Assessment.

  4. Select the preferred delivery method:

    • Email

    • SMS

  5. Confirm the patient's contact information.

  6. Send the assessment.

The patient receives a secure link that allows them to complete the questionnaire remotely.


Completing an Assessment During an Encounter

Assessments can also be administered while speaking with the patient.

  1. Open the desired assessment.

  2. Read each question to the patient.

  3. Record the patient's responses.

  4. Save the completed assessment.

The results become immediately available within the Care Plan.


Reviewing Assessment Results

After an assessment has been completed:

  • Review individual responses.

  • Verify overall scores.

  • Identify any abnormal findings.

  • Determine whether follow-up interventions are required.

Assessment results should be considered when developing SMART goals, interventions, and patient education plans.


Best Practices for Assessments

  • Use standardized assessments whenever available.

  • Encourage patients to answer honestly.

  • Review previous assessment results to identify trends.

  • Repeat assessments according to organizational policy.

  • Document any clinical observations that provide additional context.


Barriers to Care

Overview

The Barriers to Care section identifies obstacles that may prevent patients from following treatment recommendations or achieving their health goals.

Recognizing these barriers enables care teams to develop targeted interventions and improve patient engagement.


Common Barriers

Examples include:

  • Transportation difficulties

  • Financial limitations

  • Medication affordability

  • Limited caregiver support

  • Vision impairment

  • Hearing impairment

  • Mobility limitations

  • Language barriers

  • Cognitive impairment

  • Technology limitations

  • Health literacy concerns


Recording Barriers

  1. Select Barriers to Care.

  2. Review previously documented barriers.

  3. Select all applicable barriers.

  4. Add additional notes when necessary.

  5. Save the section.

Documenting barriers ensures they are considered during care planning and follow-up.


Best Practices

  • Ask open-ended questions to identify barriers that may not be immediately apparent.

  • Reassess barriers during each evaluation.

  • Update documentation whenever circumstances change.

  • Link identified barriers to appropriate interventions and community resources.


Social Determinants of Health (SDOH)

Overview

Health outcomes are influenced by more than medical conditions alone. The Social Determinants of Health (SDOH) section captures environmental, economic, and social factors that may affect a patient's ability to maintain their health.

Documenting SDOH allows care teams to identify unmet social needs and coordinate appropriate support services.


SDOH Categories

Care Plan 2.0 organizes SDOH information into several categories.

Economic Stability

Document factors such as:

  • Employment status

  • Financial hardship

  • Ability to afford medications

  • Housing affordability

  • Food security


Education

Record information related to:

  • Educational attainment

  • Health literacy

  • Ability to understand medical instructions

  • Need for educational resources


Healthcare Access

Document factors affecting healthcare utilization, including:

  • Insurance coverage

  • Access to primary care

  • Access to specialists

  • Transportation to appointments

  • Availability of pharmacies


Neighborhood & Environment

Record environmental factors such as:

  • Housing safety

  • Neighborhood conditions

  • Access to healthy food

  • Environmental hazards


Social & Community Support

Document:

  • Family support

  • Caregiver availability

  • Social isolation

  • Community involvement

  • Support groups


Completing the SDOH Section

  1. Open Social Determinants of Health.

  2. Complete each category based on the patient's responses.

  3. Record additional comments where appropriate.

  4. Save the section.

Whenever possible, discuss sensitive topics respectfully and explain why the information is important for care planning.


Best Practices for SDOH

  • Build trust before discussing sensitive topics.

  • Respect patient privacy.

  • Document only clinically relevant information.

  • Update SDOH whenever the patient's living situation changes.

  • Refer patients to available community resources when appropriate.


Vitals

Overview

The Vitals section documents the patient's physiological measurements and provides a snapshot of their current clinical status.

Depending on your organization's workflows, vitals may be:

  • Automatically received from connected RPM devices

  • Imported from integrated systems

  • Entered manually by clinical staff

Care Plan 2.0 allows users to review, add, edit, and manage vital signs directly within the Care Plan.


Supported Vital Signs

Examples may include:

  • Blood Pressure

  • Heart Rate

  • Weight

  • Blood Glucose

  • Pulse Oximetry (SpO₂)

  • Temperature

  • Respiratory Rate

  • Body Mass Index (BMI)

The available vitals depend on your organization's device integrations and configured programs.


Viewing Existing Vitals

To review previously recorded vitals:

  1. Open the Vitals section.

  2. Review the available readings.

  3. Verify that the measurements are current.

  4. Compare trends with previous visits or RPM data.


Adding a Manual Vital

If a measurement is obtained outside an integrated device:

  1. Select Add Vital.

  2. Choose the vital type.

  3. Enter the measured value.

  4. Record the date and time.

  5. Save the entry.

Manual entries should accurately reflect the patient's measurement at the time it was obtained.


Editing or Removing a Vital

Users with appropriate permissions can update or remove incorrectly entered values.

To edit:

  1. Select the vital entry.

  2. Choose Edit.

  3. Update the value.

  4. Save the changes.

To remove:

  1. Select the entry.

  2. Choose Delete.

  3. Confirm the deletion.


RPM Integration

For patients enrolled in Remote Patient Monitoring (RPM), compatible cellular or Bluetooth devices may automatically transmit readings into HealthArc.

These readings can be reviewed within the Care Plan to support clinical decision-making and ongoing monitoring.

Examples include:

  • Blood Pressure Monitor

  • Weight Scale

  • Blood Glucose Meter

  • Pulse Oximeter


Reviewing Vital Trends

When reviewing vitals:

  • Compare current readings with previous values.

  • Identify abnormal or worsening trends.

  • Confirm whether interventions have been effective.

  • Determine whether additional follow-up is necessary.

Vital trends should be considered alongside assessment results and SDOH information to provide a complete understanding of the patient's health.


Best Practices

  • Verify patient identity before recording measurements.

  • Ensure manual entries reflect the actual reading.

  • Review RPM data regularly for abnormal trends.

  • Investigate significant changes before updating the Care Plan.

  • Use the most recent clinically relevant readings when developing interventions.


Troubleshooting

I don't see any assessments.

Assessment availability depends on your organization's configured questionnaires and user permissions.

The patient didn't receive the assessment.

Verify the patient's email address or mobile number before resending the assessment invitation.

My RPM readings are not appearing.

Confirm that the patient's monitoring device is assigned correctly, has transmitted recent data, and is actively connected to the HealthArc platform.

Can I edit automatically imported vitals?

Depending on your organization's configuration, imported readings may be read-only to preserve data integrity. If corrections are needed, contact your administrator or verify the data source.

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