How to write a Care Plan
NEW! Sample Care Plan 1 | Sample Care Plan 2The documentation process varies from facility to facility but there are usually three important steps to follow:
- Initial Assessment and Planning
- Care Planning
- Evaluation.
Initial Assessment and Planning
The initial assessment involves the clinical as well as the recreational, emotional and spiritual needs of clients.It is compiled and documented in consultation with the client, family/representative and other medical and health professionals.
The ‘Social Profile’ is then completed by the family/representative and forms the basis of the Diversional Therapist assessment process. The ‘Social Profile’ should include questions regarding the resident’s leisure interests and hobbies to facilitate planning.
Care Planning
A Care Plan is a document where the specific care requirements of an individual are written to be communicated to other relevant staff. A Care Plan should state among other things:- Description the resident’s specific needs and preferences.
- Specific interventions to maintain good health, social activity and spiritual needs.
- Include current and validated risk assessment.
- Provide easily understood instructions for staff to deal with specific needs.
- Describe leisure interest and activities suitable to the individual.
- Referral to other therapies (music therapy, aromatherapy, physio therapy)
Evaluation of Care Planning
This is the accountability part of your documentation.’ Evaluation is the assessment of the effectiveness of a program in achieving its objective.’ It takes in consideration the positive and negative outcomes of the Care Plan. It gives the Diversional Therapist the opportunity to examine and judge carefully what she/he is doing to meet the resident’s individual needs.Evaluation can be done on a daily basis or at regular intervals according to the policies of your facility. Evaluation can also be done at any time the health status of your client change.
To conduct a thorough evaluation of the Care Plan, have a chat with the resident if this is possible. Ask them how are they enjoying the activities program; are they happy with the community outings? Do they miss shopping or going to a café?
If it is not possible to get this information from the resident, ask the family. Find out if the resident’s choices and preferences are still current. Talk to other members of the health care team.
In addition ask yourself some questions:
- Did the Care Plan painted an accurate picture of the resident?
- Has the resident been attending programmed activities?
Read ‘Progress Notes’ and ‘Attendance’ forms and find out if resident has been attending daily programmed activities. Amend Care Plan as required and set new goals.
Date and sign document.
NEW! Sample Care Plan 1 | Sample Care Plan 2
© Copyright Solange Kindermann 2007
HomeActivitiesMusicSocial OpportunitiesResourcesContact UsDisclaimer
Web Design Brisbane
HomeActivitiesMusicSocial OpportunitiesResourcesContact UsDisclaimer
Web Design Brisbane