Writing a Comprehensive Care Plan
We gather information on a resident by doing an assessment / resident interview. Using the information from the assessment allows us to design a comprehensive plan of care. The ICP (Interdisciplinary Care Plan) Team would then meet to form a Care Plan for a resident.
The Care Plan must address 3 areas of concern in order to be a complete plan
- The concern: What and Why
- The goal: When and How Often
- The approach: How and by Whom
Create your Care Plan
- First – define the problems / needs / concerns for your resident.What is the concern and Why is it a concern.
Resident does not attend activities due to Hard of Hearing
Resident refuses to follow diabetic diet orders
Resident unable to feed self due to Alzheimers
Question? Is the concern d/t (due to) a secondary cause, an underlying reason or is it a concern of the staff, but not for the resident?
i.e. Resident will not participate when attending an activity. This is not a problem with the resident, maybe he/she is a people watcher.. he/she just likes watching.. But the staff has a concern that he/she does not join in, still it is not a concern with the resident.
i.e. Resident prefers to eat breakfast at 10am. This is not a concern for the resident, it is a concern for dietary, unless they wont serve he/she a later breakfast, then it’s a problem, it is the residents right to have breakfast when he/she wants, and dietary should comply.
- Second– define realistic goals. Define the schedule and time limit for the goal(s) to be met.How Often will you and your resident work to acheive the goals and When will the goal be accomplished
A goal should simply address your concern, it should not be unobtainable, just a resolution to the concern. It is helpful to ask, What is the problem? The answer will lead to a realistic goal.
The goal should be a phrase or statement in which the residents progress can be evaluated and their concern resolved.
i.e.Concern: Resident is depressed
bad Goal: Resident will be less depressed. (progress cannot be measured)
good Goal: Resident will choose 2-3 activities to attend each week.
- Third– define your Approaches to obtain your goal(s) How – devise procedures / strategies to acheive the goal(s). By Whom will the procedures be conducted
The Approach is your plan or strategy to meet your goal(s) and resolve the concern. The approaches should be the steps to be taken, specific services to be offered and who is responsible for implementing the approach. Some approaches may have only one department assigned and others may have all departments assigned.
i.e. Concern: Resident is a diabetic and non-compliant with her diet d/t (due to) refusal to accept DX (diagnosis) of being a diabetic.
Goal: Resident will be compliant with diet and aware of the risks of refusal x 90d (times 90 days)
- Offer resident alternate choices in food – A,D,N (Activities, Dietary, Nursing)
- Remind resident of risk when refusing to comply with diet orders – A,D,N,S (Activities, Dietary, Nursing, Social Worker)
- If resident refuses to comply with diet, inform nursing or social worker – A,D,N,S
- Praise resident when he/she follows diet restrictions – A,N,D,S
- Ask family to stop bringing candy and other foods that are non-compliant with residents diet – A,D,N,S
- Have dietary speak with resident and family members about the disease and offer alternate foods choices – D
A-Activities, N-Nursing, D-Dietary, S-Social Worker
Approaches should not be specific tasks, make your tasks universal and non-specific to allow variety in your proceedures. Note the specifics in your progress notes.