- Get involved
Writing a good care plan
Information for people who use our services about writing a good care plan.
A care plan is a jointly agreed, written plan between you and your care co-ordinator or lead professional which outlines:
- your assessed needs
- any risks to you or others
- personal goals
- support available
- your progress towards recovery.
You will be given a copy of your care plan. Your family, carers and supporters will receive a copy of your care plan with your permission.
A care plan should include your personal goals towards recovery and self-care as well as treatment and intervention goals.
This guide is not aimed at:
- providing a step-by-step instruction, every care plan is personalised to you
- giving advice on information sharing and confidentiality, this is something that you and your care co-ordinator need to talk about and agree.
Responsibilities of your care co-ordinator
- develop and write your care plan with you
- talk to the people involved in your pathway to recovery
- send the care plan to the people involved in your care
- review your care plan with you at least every 6 months
- be optimistic, compassionate, proactive and believe in your strengths and resilience
- give relevant, timely advice to you and your carers, providing time for your carers to understand and make their own care and support decisions, including using advocates and interpreters if needed.
- what are your hopes and goals?
- how do you feel these can be achieved?
- what has worked for you in the past?
- who you are comfortable sharing information with and when this information may need to be shared without your consent.
Making sure that the information and details in your care plan are clear about explaining the responsibilities for other agencies involved in your care particularly if you have:
- been discharged from hospital in the last seven days
- a learning disability
- substance misuse problems
- safeguarding issues
- cognitive problems.
Crisis and contingency plan
The purpose of this plan is to provide you, your family, carers and supporters with timely advice and for you to know what to do when your mental health deteriorates or you are having a bad day.
The plan is based on individual needs looks at what has worked well for you in the past, who you respond/work well with, who to contact and relapse indicators.
This plan may not have been written with your full involvement if your first contact with mental health services was during a crisis.
This plan should have:
- contact details of your care co-ordinator or lead professional, community team telephone number and who to contact if they are not available
- an Out-of-Hours urgent advice contact telephone number
- GP contact telephone number
- contact telephone numbers for family and friends
- useful information and contact numbers
- any caring responsibilities (children, family or pets)
- medical conditions or allergies/ medication
- preferred method of communication
- preferred languages (to communicate)
- particular ways of behaving when distressed
- what helps or doesn’t help in an emergency or crisis?
How and where should a care plan be written?
This is an ongoing process. Plans and discussions will take place about your recovery and what it is you and your family want to get out of the care plan.
Consideration will be given to whom and what services will be supporting you on your pathway to recovery and what support is available. Self-management skills, positive risk taking and support needs for your family, carers and supporters will also be discussed.
A realistic time scale to write your care plan will be agreed with you and your care co-ordinator or lead professional.
Writing a care plan that everyone will understand
- you will be involved in developing and writing your care plan with your care co-ordinator or lead professional
- if your care co-ordinator or lead professional was not at work could other people understand your care plan
- make sure that the actions in your care plan are realistic and achievable
- explain what each action means in the care plan and who will be doing what rather than it just being an instruction
- your family, carers and supporters can be involved in writing your care plan with your permission
- think about putting ‘I’ into the care plan so it is personal to you
- you may not always agree with your care co-ordinator or lead professional and a plan about how to take this forward will be added to the care plan.
A care plan should…
- be a written record of ‘who, what, when, where, how and why’ identifying needs, personal goals, hope, actions, interventions and anticipated outcomes
- reference to your staying well plans, recovery star, my shared pathway or CHIME framework (connectedness, hope, identity, meaning and purpose in life and a sense of empowerment)
- be written in plain and simple language that can easily be understood
- identify your strengths
- reflect your cultural and ethnic background and spirituality needs
- identify any risks to you or others, including family, carers, supporters or anyone else involved in your care and support
- include contact details for your care co-ordinator or lead professional and everyone involved in providing support
- have any provisions of direct payments or individual budgets
- the next planned review date of your care plan
- include a transfer date if appropriate from one service to another
- include information on staying well and coping skills in times of difficulty
- have any specific provisions and entitlements to aftercare under section 117 of the Mental Health Act 1983
- include contact information on what to do in a mental health crisis
- include contact details for local mental health services.
Tips to make the text easy to understand in your care plan…
- avoid using jargon, and use simple words
- sometimes medical terms have to be used but make sure you understand what they are
- use short sentences of no more than 15-words
- use positive statements (avoid using negative statements)
- use small blocks of text
- typed information should usually be in Arial font, font size should be between 12 and 16 point.
- large bold font to emphasises text
- try not to use UPPER CASE letters, italics and underlining as these make the text more difficult for you to read.
- make sure the bullet points make sense on their own
- use active sentences not passive sentences, for example; ‘your appointment is on…’ not ‘your appointment has been made for …’.
Examples of a way to write a personalised care plan….
- ‘I will attend therapy sessions for support with my anxiety every Wednesday’
- ‘My husband will support me with my breathing exercises if I have a panic attack’
- ‘I will work with my GP to reduce the amount of tablets I take for my anxiety at my next appointment on 5/10/15’
- ‘At the end of the treatment I will talk to my care co-ordinator Julie, about a discharge plan from the current team’
L882, v3, 15/03/21, archive 14/03/24
Follow us on social media for all the latest news and announcements
How to write a person-centred care plan?
In this post, you'll learn how to write a care plan .
We'll answer several questions around that topic.
What is a person centred care plan and how do you make one?
Does a care plan need to be person centred?
What are the benefits of using a person centred planning approach?
Can software help you create person centred care plans?
If you’ve ever wondered about any of the above - you’re in the right place.
“People using a service have care or treatment that is personalised specifically for them. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.”
(You can read the full regulation here )
So what does that mean for you?
If you’re a care provider, you need to ensure that your care plans are person centred .
People might also use terms such as patient-centred, family-centred, user-centred, individualised or personalised, but they all mean the same thing.
What Is A Personalised Care Plan?
A personalised care plan is simply a record of the outcomes of a care planning discussion between an individual and their health or social care professional.
Whether you develop your own care plan or use a template, personalised care plans are key.
You may already be working with certain plans that schedule treatments or medication, but a truly personalised care plan should include other information such as SMART goals , preferences and personal information.
The most important aspect of a care plan is the initial discussion, as this will help you to build the complete picture.
Care Plan Templates
There is no national template for care plans, because a care plan should be a fluid document that is adapted to every individual. However, there are key domains to care planning that can be considered which may help local organisations and staff in developing local care plans.
If you want to know how to write a care plan , follow these instructions.
Every care plan should include:
- Personal details
- A discussion around health and well being goals and aspirations
- A discussion about information needs
- A discussion about self care and support for self care
- Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes
- Any actions agreed
- A review date
The Health Foundation has identified a framework that comprises four principles of person-centred care:
- affording people dignity, compassion and respect
- offering coordinated care, support or treatment
- offering personalised care, support or treatment
- supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life.
We’ll talk about a few ways to incorporate these principles into care planning below:
Read also: How to setup a care agency
Ensure Personalised Care Plans Aren’t One-Size-Fits-All
It’s perfectly acceptable to use a care planning template for every person you care for, as long as they are used as a starting point, and not a complete document. Using a pre-existing care plan template helps to save time and can help you make sure you’ve not forgotten anything. But, in order to make sure they’re person centred, they need to focus on the goals and priorities of each person, with outcomes to match.
Paper care plans (and care delivery recorded on paper) is soon to be replaced by digital means, with the CQC and NHS driving the digital change. If you’re thinking about making the switch to a care planning software solution, here’s an example of how we create person centred care plans at Birdie - using guide templates for you to expand on.
Check out the benefits of digital vs paper care planning, here.
When you use Birdie to plan your care, you'll find a number of categories for you to fill in.
In each category, you'll be asked a number of questions about your care recipient’s level of independence so you can create a person centred care plan which fully understands their needs. You can also record any risks that you may observe in order to decide whether further assessments are needed.
From there, you can add tasks which will help the client achieve those outcomes. You can add your own notes to each one, which make them really person centred, and you can see in real time when they’ve been completed.
Read also: Top questions for person-centered care planning
Focus On What The Person Can Do
When planning for home care, you’ll need to specify whether or not a person can physically do something, so your team can assist appropriately. But in order to make a care plan person centred, you’ll need to speak with your clients to gauge what they can do, and what they would like to do. Whilst it may be clear that they cannot walk unaided, they may get great satisfaction from choosing how they dress, or the activities they enjoy. By focusing on their strengths, you can build a care plan that helps to support their goals.
“Recognise that people have preferences, aspirations and potential throughout their lives, and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.”
Read also: eMar system - what you need to know
Keep Everyone Involved
Learning how to write a care plan means making sure that everyone has a say - and treating everyone involved in the care of a person as an extended team member (yes, even the person you’re caring for!)
Treat the people who use your services with empathy and respect; ask them about their wishes, their likes and dislikes and factors that will influence the care you provide.
Agree on mutual expectations and be sure to review these frequently, involving all parties in any decisions.
A great example comes from our partner agency, Harino Care. Tracey the Registered Manager told us:
“For example one of the tasks would be a normal assist wash in the mornings, but we would make that person-centred, by saying ‘the bowl is in the kitchen, please use the yellow flannel for the top. Mrs Smith prefers to use X bubble bath’
You should also ensure that wherever possible you’re respecting the privacy of those you care for. If you use paper care plans, kept in a person’s home, this means some potentially private information is available to any visitors to their home. Speak to your clients and ask them what they’re happy to share - and if you can, use a home care planning software like Birdie , to ensure that sensitive data is never left out in a person’s home.
You'll also like: Domiciliary care - Complete guide
Ask For Feedback (And Action It!)
Asking for feedback can seem like opening a can of worms. With so many people involved in a single person’s care, there will be many opinions that need to be respected. But, if you’ve created a person-centred approach to care planning from the start, this step should be relatively pain-free.
If you receive feedback that highlights improvements or requests, be sure to communicate what you’ll do to action it.
The easiest way to gather feedback is through a survey, which you can create quickly online and send quickly via email. Typeform and Google Forms are great tools for this.
You should also be in regular contact with the people you care for, to offer them the opportunity to direct and discuss their care. Find out what’s working for them, what they’d like more of and how you can support it. This helps to maintain a person-centred approach and ensures they are always in control of their care.
If you need some guidance on how to have an effective conversation, check out some tips, here.
Read also: Everything you need to know about advanced care planning
Strive for continuity of care
It’s not always possible to assign your care team to the same people all the time. But, wherever possible you should strive to ensure the person is supported by the same home care worker(s) so they can become familiar with them.
You should also be actively trying to ‘match’ your team members to the people you care for, taking into account: the person's care and support needs, and the care workers' skills, and if possible and appropriate, both parties' interests and preferences.
Birdie provides in depth reports that allow you to see the percentage of visits to a client by one care professional, so you always have visibility over your care continuity and you can make changes weekly (when you receive your report). If you’re interested in knowing more about our data and analytics service at Birdie, you can watch our on-demand webinar where we spoke with our partner agency Caring Crew about the impact of data on care planning, or you speak with our team by booking a free demo, here.
Learn more about digital care planning software
The Key Takeaway On How To Write A Care Plan
It’s important to remember that although person centred care planning can stem from a number of activities, it needs to be integrated into everything you do at your home care agency.
The idea of person centred care planning is underpinned by the philosophy of doing things ‘with’ people, rather than ‘to’ them. You need to be flexible to meet people’s needs and work with people and their families to find the best way to provide their care.
If you stick to the above principles with your care planning, you can expect to score highly when you’re inspected by the CQC. You can see the CQC KLOEs here, to review how your person centred planning will assist with hitting their requirements.
Birdie recently partnered with Home Instead ! Find out more about how the journey is going here:
If you're thinking about going digital, read up on the benefits of digital care plans vs paper care plans, here. Find out more about person centred care planning, here or get a free SMART care plan template, here .
Discover our care scheduling software
Medication Administration Record: Safeguarding UK Domiciliary Care
This article will delve into what MAR is, the importance and role of Medication Administration Records, their practical applications in domiciliary care, the digital shift in record-keeping, and the paramount significance of patient safety.
Top 8 Digital Care Management Systems
Digital care management systems streamline operations, enhance communication, and ultimately improve the quality of care provided to care recipients. In this article, we'll explore the top 8 digital care management systems, with a focus on addressing the unique needs of homecare and domiciliary care providers.
What's new at Birdie: November 2023
This month we launched one of our most highly-requested features, a brand new Message Centre that lets you send real-time updates to your Care Professionals, along with some exciting new Care Management and Finance tools!
Let us show you how birdie can help
You're the expert. You deserve home healthcare technology that motivates your team and helps you grow.
Join our mailing list
Nursing Care Plans (NCP): Ultimate Guide and List
Writing the best nursing care plan requires a step-by-step approach to complete the parts needed for a care plan correctly. This tutorial will walk you through developing a care plan. This guide has the ultimate database and list of nursing care plans (NCP) and nursing diagnosis samples for our student nurses and professional nurses to use—all for free! Care plan components, examples, objectives, and purposes are included with a detailed guide on writing an excellent nursing care plan or a template for your unit.
Table of Contents
Standardized care plans, individualized care plans, purposes of a nursing care plan, three-column format, four-column format, student care plans, step 1: data collection or assessment, step 2: data analysis and organization, step 3: formulating your nursing diagnoses, step 4: setting priorities, short-term and long-term goals, components of goals and desired outcomes, types of nursing interventions, step 7: providing rationale, step 8: evaluation, step 9: putting it on paper, basic nursing and general care plans, surgery and perioperative care plans, cardiac care plans, endocrine and metabolic care plans, gastrointestinal, hematologic and lymphatic, infectious diseases, integumentary, maternal and newborn care plans, mental health and psychiatric, musculoskeletal, neurological, pediatric nursing care plans, reproductive, respiratory, recommended resources, references and sources, what is a nursing care plan.
A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes a client’s potential needs or risks. Care plans provide a way of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.
Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.
Types of Nursing Care Plans
Care plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurse ‘s mind. A formal nursing care plan is a written or computerized guide that organizes the client’s care information.
Formal care plans are further subdivided into standardized care plans and individualized care plans: Standardized care plans specify the nursing care for groups of clients with everyday needs. Individualized care plans are tailored to meet a specific client’s unique needs or needs that are not addressed by the standardized care plan.
Standardized care plans are pre-developed guides by the nursing staff and health care agencies to ensure that patients with a particular condition receive consistent care. These care plans are used to ensure that minimally acceptable criteria are met and to promote the efficient use of the nurse’s time by removing the need to develop common activities that are done repeatedly for many of the clients on a nursing unit.
Standardized care plans are not tailored to a patient’s specific needs and goals and can provide a starting point for developing an individualized care plan .
Care plans listed in this guide are standard care plans which can serve as a framework or direction to develop an individualized care plan.
An individualized care plan care plan involves tailoring a standardized care plan to meet the specific needs and goals of the individual client and use approaches shown to be effective for a particular client. This approach allows more personalized and holistic care better suited to the client’s unique needs, strengths, and goals.
Additionally, individualized care plans can improve patient satisfaction . When patients feel that their care is tailored to their specific needs, they are more likely to feel heard and valued, leading to increased satisfaction with their care. This is particularly important in today’s healthcare environment, where patient satisfaction is increasingly used as a quality measure.
Tips on how to individualize a nursing care plan:
- Perform a comprehensive assessment of the patient’s health, history, health status, and desired goals.
- Involve the patient in the care planning process by asking them about their health goals and preferences. By involving the client, nurses can ensure that the care plan is aligned with the patient’s goals and preferences which can improve patient engagement and compliance with the care plan.
- Perform an ongoing assessment and evaluation as the patient’s health and goals can change. Adjust the care plan accordingly.
The following are the goals and objectives of writing a nursing care plan:
- Promote evidence-based nursing care and render pleasant and familiar conditions in hospitals or health centers.
- Support holistic care, which involves the whole person, including physical, psychological, social, and spiritual, with the management and prevention of the disease.
- Establish programs such as care pathways and care bundles. Care pathways involve a team effort to reach a consensus regarding standards of care and expected outcomes. In contrast, care bundles are related to best practices concerning care for a specific disease.
- Identify and distinguish goals and expected outcomes.
- Review communication and documentation of the care plan.
- Measure nursing care.
The following are the purposes and importance of writing a nursing care plan:
- Defines nurse’s role. Care plans help identify nurses’ unique and independent role in attending to clients’ overall health and well-being without relying entirely on a physician’s orders or interventions.
- Provides direction for individualized care of the client. It serves as a roadmap for the care that will be provided to the patient and allows the nurse to think critically in developing interventions directly tailored to the individual.
- Continuity of care. Nurses from different shifts or departments can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
- Coordinate care. Ensures that all members of the healthcare team are aware of the patient’s care needs and the actions that need to be taken to meet those needs preventing gaps in care.
- Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
- Serves as a guide for assigning a specific staff to a specific client. There are instances when a client’s care needs to be assigned to staff with particular and precise skills.
- Monitor progress. To help track the patient’s progress and make necessary adjustments to the care plan as the patient’s health status and goals change.
- Serves as a guide for reimbursement. The insurance companies use the medical record to determine what they will pay concerning the hospital care received by the client.
- Defines client’s goals. It benefits nurses and clients by involving them in their treatment and care.
A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, nursing interventions, and rationales. These components are elaborated on below:
- Client health assessment , medical results, and diagnostic reports are the first steps to developing a care plan. In particular, client assessment relates to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Information in this area can be subjective and objective.
- Nursing diagnosis . A nursing diagnosis is a statement that describes the patient’s health issue or concern. It is based on the information gathered about the patient’s health status during the assessment.
- Expected client outcomes. These are specific goals that will be achieved through nursing interventions. These may be long and short-term.
- Nursing interventions . These are specific actions that will be taken to address the nursing diagnosis and achieve expected outcomes . They should be based on best practices and evidence-based guidelines.
- Rationales. These are evidence-based explanations for the nursing interventions specified.
- Evaluation . These includes plans for monitoring and evaluating a patient’s progress and making necessary adjustments to the care plan as the patient’s health status and goals change.
Care Plan Formats
Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan where goals and evaluation are in the same column. Other agencies have a five-column plan that includes a column for assessment cues.
The three-column plan has a column for nursing diagnosis, outcomes and evaluation, and interventions.
This format includes columns for nursing diagnosis, goals and outcomes, interventions, and evaluation.
Below is a document containing sample templates for the different nursing care plan formats. Please feel free to edit, modify, and share the template.
Download: Printable Nursing Care Plan Templates and Formats
Student care plans are more lengthy and detailed than care plans used by working nurses because they serve as a learning activity for the student nurse.
Care plans by student nurses are usually required to be handwritten and have an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales are scientific principles that explain the reasons for selecting a particular nursing intervention.
Writing a Nursing Care Plan
How do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan for your client.
The first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, and diagnostic studies). A client database includes all the health information gathered . In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have specific assessment formats you can use.
Now that you have information about the client’s health, analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes.
Nursing diagnoses are a uniform way of identifying, focusing on and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses.
We’ve detailed the steps on how to formulate your nursing diagnoses in this guide: Nursing Diagnosis (NDx): Complete Guide and List .
Setting priorities involves establishing a preferential sequence for addressing nursing diagnoses and interventions. In this step, the nurse and the client begin planning which of the identified problems requires attention first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening problems should be given high priority.
A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved, such as self-esteem and self-actualization. Physiological and safety needs are the basis for implementing nursing care and interventions. Thus, they are at the base of Maslow’s pyramid, laying the foundation for physical and emotional health.
Maslow’s Hierarchy of Needs
- Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep , sex, shelter, and exercise.
- Safety and Security: Injury prevention ( side rails , call lights, hand hygiene , isolation , suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety ( therapeutic relationship ), patient education (modifiable risk factors for stroke , heart disease).
- Love and Belonging: Foster supportive relationships, methods to avoid social isolation ( bullying ), employ active listening techniques, therapeutic communication , and sexual intimacy.
- Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
- Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.
The client’s health values and beliefs, priorities, resources available, and urgency are factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation.
Step 5: Establishing Client Goals and Desired Outcomes
After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.
One overall goal is determined for each nursing diagnosis. The terms “ goal outcomes “ and “expected outcome s” are often used interchangeably.
According to Hamilton and Price (2013), goals should be SMART . SMART stands for specific, measurable, attainable, realistic, and time-oriented goals.
- Specific. It should be clear, significant, and sensible for a goal to be effective.
- Measurable or Meaningful. Making sure a goal is measurable makes it easier to monitor progress and know when it reaches the desired result.
- Attainable or Action-Oriented. Goals should be flexible but remain possible.
- Realistic or Results-Oriented. This is important to look forward to effective and successful outcomes by keeping in mind the available resources at hand.
- Timely or Time-Oriented. Every goal needs a designated time parameter, a deadline to focus on, and something to work toward.
Hogston (2011) suggests using the REEPIG standards to ensure that care is of the highest standards. By this means, nursing care plans should be:
- Realistic. Given available resources.
- Explicitly stated. Be clear about precisely what must be done, so there is no room for misinterpretation of instructions.
- Evidence-based. That there is research that supports what is being proposed.
- Prioritized. The most urgent problems are being dealt with first.
- Involve. Involve both the patient and other members of the multidisciplinary team who are going to be involved in implementing the care.
- Goal-centered. That the care planned will meet and achieve the goal set.
Goals and expected outcomes must be measurable and client-centered. Goals are constructed by focusing on problem prevention, resolution, and rehabilitation. Goals can be short-term or long-term . Most goals are short-term in an acute care setting since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or live at home, in nursing homes, or in extended-care facilities.
- Short-term goal . A statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days.
- Long-term goal . Indicates an objective to be completed over a longer period, usually weeks or months.
- Discharge planning . Involves naming long-term goals, therefore promoting continued restorative care and problem resolution through home health, physical therapy, or various other referral sources.
Goals or desired outcome statements usually have four components: a subject, a verb, conditions or modifiers, and a criterion of desired performance.
- Subject. The subject is the client, any part of the client, or some attribute of the client (i.e., pulse, temperature, urinary output). That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise (family, significant other ).
- Verb. The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.
- Conditions or modifiers. These are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.
- Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These are optional.
When writing goals and desired outcomes, the nurse should follow these tips:
- Write goals and outcomes in terms of client responses and not as activities of the nurse. Begin each goal with “Client will […]” help focus the goal on client behavior and responses.
- Avoid writing goals on what the nurse hopes to accomplish, and focus on what the client will do.
- Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.
- Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.
- Ensure that goals are compatible with the therapies of other professionals.
- Ensure that each goal is derived from only one nursing diagnosis. Keeping it this way facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set.
- Lastly, make sure that the client considers the goals important and values them to ensure cooperation.
Step 6: Selecting Nursing Interventions
Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the priority nursing problem or diagnosis. As for risk nursing problems, interventions should focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process ; however, they are actually performed during the implementation step.
Nursing interventions can be independent, dependent, or collaborative:
- Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgement and skills. Includes: ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.
- Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy , diagnostic tests, treatments, diet, and activity or rest. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.
- Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint.
Nursing interventions should be:
- Safe and appropriate for the client’s age, health, and condition.
- Achievable with the resources and time available.
- Inline with the client’s values, culture, and beliefs.
- Inline with other therapies.
- Based on nursing knowledge and experience or knowledge from relevant sciences.
When writing nursing interventions, follow these tips:
- Write the date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.
- Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “ Educate parents on how to take temperature and notify of any changes,” or “ Assess urine for color, amount, odor, and turbidity.”
- Use only abbreviations accepted by the institution.
Rationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP.
Rationales do not appear in regular care plans. They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention.
Evaluation is a planned, ongoing, purposeful activity in which the client’s progress towards achieving goals or desired outcomes is assessed, and the effectiveness of the nursing care plan (NCP). Evaluation is an essential aspect of the nursing process because the conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed.
The client’s care plan is documented according to hospital policy and becomes part of the client’s permanent medical record, which may be reviewed by the oncoming nurse. Different nursing programs have different care plan formats. Most are designed so that the student systematically proceeds through the interrelated steps of the nursing process , and many use a five-column format.
Nursing Care Plan List
This section lists the sample nursing care plans (NCP) and nursing diagnoses for various diseases and health conditions. They are segmented into categories:
Miscellaneous nursing care plans examples that don’t fit other categories:
Care plans that involve surgical intervention.
Nursing care plans about the different diseases of the cardiovascular system :
Nursing care plans (NCP) related to the endocrine system and metabolism:
Care plans (NCP) covering the disorders of the gastrointestinal and digestive system :
Care plans related to the hematologic and lymphatic system :
NCPs for communicable and infectious diseases:
All about disorders and conditions affecting the integumentary system :
Nursing care plans about the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
Care plans for mental health and psychiatric nursing:
Care plans related to the musculoskeletal system:
Nursing care plans (NCP) for related to nervous system disorders:
Care plans relating to eye disorders:
Nursing care plans (NCP) for pediatric conditions and diseases:
Care plans related to the reproductive and sexual function disorders:
Care plans for respiratory system disorders:
Care plans related to the kidney and urinary system disorders:
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Recommended reading materials and sources for this NCP guide:
- Björvell, C., Thorell-Ekstrand, I., & Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record. BMJ Quality & Safety , 9 (1), 6-13. [ Link ]
- DeLaune, S. C., & Ladner, P. K. (2011). Fundamentals of nursing: Standards and practice . Cengage learning.
- Freitas, F. A., & Leonard, L. J. (2011). Maslow’s hierarchy of needs and student academic success . Teaching and learning in Nursing , 6 (1), 9-13.
- Hamilton, P., & Price, T. (2007). The nursing process, holistic. Foundations of Nursing Practice E-Book: Fundamentals of Holistic Care , 349.
- Lee, T. T. (2004). Evaluation of computerized nursing care plan: instrument development . Journal of Professional Nursing , 20 (4), 230-238.
- Lee, T. T. (2006). Nurses’ perceptions of their documentation experiences in a computerized nursing care planning system . Journal of Clinical Nursing , 15 (11), 1376-1382.
- Rn, B. O. C., Rn, H. M., Rn, D. T., & Rn, F. E. (2000). Documenting and communicating patient care: Are nursing care plans redundant?. International Journal of Nursing Practice , 6 (5), 276-280.
- Stonehouse, D. (2017). Understanding the nursing process . British Journal of Healthcare Assistants , 11 (8), 388-391.
- Yildirim, B., & Ozkahraman, S. (2011). Critical thinking in nursing process and education . International journal of humanities and social science , 1 (13), 257-262.
60 thoughts on “Nursing Care Plans (NCP): Ultimate Guide and List”
This page is helpful!
Thank you! Hope we’ve helped you write better nursing care plans!
Will definitely use this site to help write care plans. How should I cite this link when using APA format. Thank You
HI Can some one help me to do assignment on Impaired renal perfusion. 1.Goal 2.Related Action 3.Rational 4.Evaluate outcome
Wow God bless plenty Nurseslabs really relieve my burdens 😊😊
Thank you for all this useful info! I have been looking for something like this online.
You’re welcome! :)
Quite educative thank you
The notes were indeed useful
I hope to learn more and improve my skills towards nursing
Thank you so so much! This website is of great assistance to me. God bless you.
It’s so great for nursing student
Very beautiful ,Good work keep it up
Nice work. Well done
Great job,thank you
Thanks so much , it’s of much support for students .
Risk for ineffective thermoregulation would be a good one for you to do next for newborn.
Hi, i have learnt a lot THANK YOU. i would kindly like to learn more on paper 1 since am yet to sit for my nursing council exams and feel challenged on the paper.please do assist me thank you.
This site is a total lifesaver!
What is a nursing care plan a mother in second stage of labour?
Please see: 36 Labor Stages, Induced and Augmented Labor Nursing Care Plans
What is the nursing care plan for pulmonary oedema?
I m interest in receiving a blank nursing care plan template for my students to type on. I was wondering if it was available and if so can you please direct me on where to find it?
Hi! You can download it here: Nursing Care Plan Template
I love this website!!! Is there a textbook version of the Nurseslabs that I can purchase??
Thank you Nurseslabs. This is a wonderful note you’ve prepared for all nurses. I would like a pdf of this. Thanks.
I wish I had had this resource when i was in nursing school 2008!!
Yeah! It’s nice
Thanks for this information!
God bless you sis…Thank you for all this useful info!
This is the kind of step-by-step guidance that I needed. Thank you!
Thank you. I have learned a lot!
Wow! This is a hidden treasure!
Thanks a lot for this, it is really helpful!
Hi Matt! I would like to purchase a textbook of your nursing care plan. Where I can purchase pls help!
Sorry, we don’t have a textbook. All of our resources are here on the website and free to use.
Good day, I would like to know how can I use your website to help students with care plans.
Sincerely, Oscar A. Acosta DNP, RN
Oh I love your works. Your explanations
I’m glad I’ve met your website. It helps me a lot. Thank you
I love this, so helpful.
These care plans are great for using as a template. I don’t have to reinvent the wheel, and the information you provided will ensure that I include the important data without leaving things out. Thanks a million!
Hi, I have learnt a lot, this is a wonderful note you’ve prepared for all nurses thank you.
Matt, this page is very informative and I especially appreciate seeing care plans for patients with neurological disorders. I notice, though, that traumatic brain injury is not on your list. Might you add a care plan page for this?
Thanks alot I had gained much since these are detailed notes 🙏🙏
OMG, this is amazing!
Wow very helpful.thank you very much🙏🙏
Hi, is there a downloadable version of this, pdf or other files maybe this is awesome!
Hi Paul, on your browser go to File > Print > Save as PDF. Hope that helps and thanks for visiting Nurseslabs!
Matt, I’m a nursing instructor looking for tools to teach this. I am interested in where we can find “rules” for establishing “related to” sections…for example –not able to utilize medical diagnosis as a “related to” etc. Also, resources for nursing rationale.
Hello, please check out our guide on how to write nursing diagnoses here: https://nurseslabs.com/nursing-diagnosis/
Nursing care plan is very amazing
Thanks for your time. Nursing Care Plan looks great and helpful!
complete knowledge i get from here
great resource. puts it all together. Thank for making it free for all
Hello Ujunwa, Thanks a lot for the positive vibes! 🌟 It’s super important to us that everyone has access to quality resources. Just wondering, is there any specific topic or area you’d love to see more about? We’re always looking to improve and add value!
Hi Abbas, Thank you so much! Really glad to hear you found the nursing care plans guide useful. If there’s a specific area or topic you’re keen on exploring more, or if you have any suggestions for improvement, feel free to share. Always aiming to make our resources as helpful as possible!
Leave a Comment Cancel reply
What is a Care Plan In a Care Home? Why They're Important
Estimated Reading Time: 10 minutes
Customer Care Expert
Last Updated: 15/11/2023
If you’ve been found as needing care and support after a care needs assessment takes place, you’ll get a care plan. This carefully lays out the help you can expect to receive and how this will be given.
We’ve also highlighted the importance of care and support plans, what they contain and different plan types.
Kickstart your care search
Discover the best care homes in your area through Lottie.
In this article on care plans:
- What is a care plan?
- Why are care plans important?
- Making a care plan
- Types of care plans
- Daily care plans
- Involving the person
- Care plan reviews
- How to complain if you aren’t happy
- How to check staff are following care plans
- Care plans in care homes
What is a Care Plan?
Care plans are created for individuals in care who need support; whether it’s simple assistance with day-to-day tasks and support taking medication, all the way to round-the-clock supervision and ongoing medical care.
It will clearly lay out the level of support a person needs, how the support will be given, what the aims and goals of the care are and any other necessary details.
Why are Care Plans Important?
Care plans are extremely important and every person receiving care - whether that’s through home care or in a care home - should have one.
Not only do they give the individual achievable goals, aims and structure for their care, but they also help promote independence in care , allowing them to retain as much control as possible over their life and continue to do the things they love and enjoy.
Another benefit of support plans is that they help the person’s family members and loved ones to better understand their care needs, health conditions and how they can offer additional support with day-to-day tasks.
The support planning process is essential to ensure that the care seeker consistently receives the right level of care and that their requirements and personal preferences are known by any staff in charge of their care. For example, a carer or personal assistant visiting your loved one at home should know their exact requirements.
Care plans are important in several other ways as well:
- They record conversations, decisions and agreed outcomes in an easy-to-understand way for the person receiving care
- They outline the description of a person, why their plan is achievable and effective, and what matters to them most within the plan
- They help to ensure care is coordinated and focused on a specific person’s health and wellbeing needs - person-centred care
Making a Care Plan
To get your care plan, you’ll need to get in touch with the social services department at your local council to arrange a care needs assessment.
A needs assessment will look at your unique care requirements and the level of support you need, as well as the type of care that would best suit you.
This will then be written up, which can take a couple of weeks. You should have a say in what goes into your it, so don’t be afraid to voice personal wishes for your own care, no matter how big or small.
You can also get a support plan if you are caring for someone else – you’ll have to do a separate assessment, known as a carer’s assessment, from your local authority.
What support should be included in a care plan?
As care plans are tailor-made for the individual, no two should be the same. However, there are some common things that tend to be included, such as:
- A photo of the resident for easy identification
- Goals and aspirations: What the care seeker wants to get out of their care
- The care seeker’s hobbies, likes, dislikes and preferences on meals and daily routine
- Who is paying for the care: The care seeker’s personal budget
- Payment details
- Details of key dates and life events (this is particularly important for care seekers with dementia)
- Medical history and details on how much independence the care seeker has
- Equipment, home adaptations, or specific medical care needed
- Details of continuity of care and emergency contacts
- Details of end of life care , if required (this is often offered in a palliative care home )
As well as medical history, details of medication and history of injuries and illness, a good care plan may also include information about the person’s history, employment history, family, culture and religion to give carers and staff a complete understanding of the person.
Types of Care Plans
Along with broader care and support plans, there are also more specific plans aimed at catering to people with often specialist care needs, including people who require nursing or dementia care. Below, we’ve explained how the different types may differ.
Nursing care plans
Nursing care plans are similar to general care plans, with the exception that they likely contain more specific information on medication, specific care needed for certain health conditions and equipment or adaptations someone might need in their home or care home.
Any changes to the resident’s health condition will be carefully noted in their health record and their support needs will be updated.
Ensuring plans are regularly updated will ensure that staff switching shifts are all on the same page and can pick up where the last carer left off to make sure nothing is missed. It also means that all care needs will be met.
Dementia care plans
Dementia residents will have a dementia care plan that includes a more personal account of who they are. These plans are written to help caregivers understand a resident on a more personal level, including things like their background and life story and the best ways to communicate with them.
The ultimate goal of a dementia care plan is for a carer to read it and be able to answer “who is this person?” and “what makes them tick?” In this way, the plan provides a voice for somebody when they’re often unable to provide it themselves.
Alzheimer’s care plans
Alzheimer’s is the most common form of dementia. An Alzheimer’s care plan often focuses on meaningful activities that provide enjoyment and structure for residents.
An Alzheimer’s care plan will take into account:
- Your loved one’s likes, dislikes, strengths and interests
- How they used to structure their day
- The best times for meals, bathing and dressing
- Regular times for waking up and going to bed (this is particularly useful if your loved one with dementia experiences sundowning )
Daily Care Plans
Although care plans look at the long-term aspect of someone’s care, daily records are also important.
Daily records help care home staff stay on top of residents’ care, especially in a care home where there are multiple members of staff on different shifts.
Staff should use the information in a care plan to tailor their approach to each individual – whether that’s remembering which foods someone is allergic to, or knowing which residents would be interested in doing a singing class.
Care plans also ensure that staff and residents can work together to achieve the person’s care goals; for example, completing daily physio exercises to help the person maintain their mobility.
Most care homes will update care records daily to make sure staff have the right information at the right time, reducing the likelihood of accidents and keeping residents happy and well-cared for.
Involving the Person
The most important thing about care planning is that it should be created around the person in question.
If it’s your care plan, make sure your opinions are heard and that you have a clear understanding of what is going into your care.
If the care plan is for your relative or loved one, don’t leave them out of conversations about their care and involve them in every decision. Their wants and wishes should be prioritised to ensure they are healthy and happy at all times.
Even if the care seeker in question has dementia, mental health problems, a disability or the person lacks capacity they should still be included at every step of the way; from the first conversation about their care, to ongoing care plan reviews.
Facial expressions, body language, gestures and behaviours can be used to communicate if speech is not always possible. Communication is key and can make all the difference between someone being unhappy in care and someone having the best experience possible.
Care Plan Reviews
Care plans are flexible and can easily be updated or amended at any time. If your local council has arranged your care and support plan, they have a duty to review it and make changes or updates if needed.
The first time your care plan is reviewed should be within three months after it has first been made. After that, you should have a care plan review at least once a year – but this isn’t set in stone.
If you ever feel your plan is no longer supporting your needs, or you want to lodge a complaint , we've explained below.
How to Complain If You Aren't Happy
Your care plan should be reviewed regularly, giving you an opportunity to say what’s working and not working, and whether you want any changes to be made.
If you are unhappy with your care plan, you can get in touch with adult social services at your local council to request a review.
Most local councils have a formal complaints procedure in place that you can follow by going to their website. If this is unsuccessful, you can escalate your complaint to your local government and social care ombudsman.
Ask a family member or a friend to help you make your complaint if you cannot easily access the Internet or phone.
How to Check Staff are Following Care Plans
When you’re researching care homes, look for evidence that the staff clearly understand and use care plans. Staff should ask for residents’ preferences each time they provide care or support; for example, asking residents when they’d like their medication, asking what they’d like for dinner, or remembering that they have sugar in their tea.
If staff are friendly, respectful, informative and happy to talk to friends and family about their loved one’s care, this is another good sign.
Finally, if you can see evidence that the staff and care team are consistently reviewing residents’ plans, asking for feedback from all parties involved and taking steps to offer care plan reviews, it’s probably a great care home to live in!
Care Plans in Care Homes
When somebody moves into a care home, a plan for their care is essential in making sure they have all the support that’s needed to feel healthy and happy within the home.
Most care homes use a standard format for care planning, meaning new members of staff can quickly adapt and support your loved one.
In a care home, the best support plans will also inform and update family members so they can contribute to care planning. Having family involved from the get-go will make providing compassionate and personal care easier for staff. They’ll get a better understanding of likes and dislikes, lifestyle and skills.
Lottie matches care seekers with the best care homes for their needs. You can request a free care home shortlist from our care experts, who will share homes matching your budget, location and type of care needed. You can also search for a care home through our easy-to-use directory.
Frequently Asked Questions
Not only does a care plan help support care workers in providing a superb standard of care for yourself or your loved one, but they also enable carers to best understand the level and type of care every resident should receive, dependent on their individual needs. Care plans are essential as they provide a detailed outline of exactly what care and support needs to be provided.
Care plans are almost always made following an assessment and are written by care professionals. The person who is due to receive care will be supported to express how they’d like their care and support to be delivered. The care professional writing the plan will provide information about what services can be offered.
If your local council has arranged support for you, this must be reviewed within a ‘reasonable time frame’ (normally within three months). After these initial three months, your care plan should then be reviewed at least once a year (or more often if needed).
Request a Free Shortlist
Kickstart your search with Lottie and request a free care home or retirement living shortlist, created by our team of experts.
Similar Blog Posts
What is a Care Plan?
How your care plan informs your services and support for in home care.
When receiving coordinated services and support through any government subsidised aged care program, one very important document needs to be created – the care plan.
Whether the older person has received approval for a flexible care package such as Short Term Restorative Care (STRC) or Transition Care Program (TCP), or a longer-term package of funding such as a home care package (HCP) , when the services are set up, the care plan is an essential document.
What is a care plan?
The care plan is a document that takes into account a person's medical history, any functional or mobility impairment and any tasks that the older person needs help with from day to day.
The care plan reflects any religious, spiritual or cultural considerations for the individual.
It should document the personalised needs and goals of the older person,
the recipient of care.
It should be developed with these needs and goals as a priority and aim to address what services and support can be put in place to meet them.
A care plan is not a generic form that is a “one size fits all”, nor is it a document that is completed once and then filed away safely.
A care plan evolves with the changing needs of the client, being updated to reflect the elderly client’s situation, whether that be their general health, cognition, mobility, or any other aspect that impacts their ability to live well at home.
A care plan should be reviewed at least annually, more often if there have been significant changes in the person's health or wellbeing.
What detail should be in a care plan?
A good care plan is developed in conjunction with the older person.
Home care package providers often task the care manager with writing the care plan.
While this might be acceptable for the lower-level packages, there is an expectation that for higher level packages, the level 3 and 4 packages, that a nurse is involved in the development of the care plan.
People who are approved for the higher level packages usually have more complex needs associated with health conditions and having a registered nurse involved in the development of the care plan ensures a person's needs are comprehensively assessed and incorporated into the care planning.
A registered nurse will also be able to detect unmet needs in the care planning and screen and apply for other Government schemes outside the aged care program.
A care plan should be a detailed document and take into account the preferences of the older person.
The care plan should never be developed solely from the perspective of the package provider.
Considerations for care planning should include:
Any medical conditions that need to be addressed? Can the package fund purchases that will help relieve these conditions?
Respiratory conditions such as asthma or Chronic Obstructive Pulmonary Disease would indicate maintaining a clean house free of allergens and the care plan should include regular cleaning of all surfaces as well as cleaning airconditioners to decrease the risk of the person having an exacerbation of their condition.
There is much discussion around cleaning of airconditioners since January 2023, with the updated home care package manual excluding this service, but if you can demonstrate the risk to your health by not having this type of cleaning attended, your provider should support this request.
Having your respiratory condition documented in your care plan, as well as the support the provider is offering to mitigate the risk to your health, will help you get this service approved and help your provider justify to auditors, why they have allowed this kind of expenditure.
People who have diabetes should have included in their care plan regular reviews with a podiatrist to ensure monitoring of the nerves in their feet occurs and if the podiatrist recommends protective or supportive footwear, this could also be included in package expenditure.
People with diabetes should also have included in their care plan the option to see a dietician.
And purchases such as a robotic vacuum cleaner that could be programmed to clean the floors every day, if the older person cannot manage to keep their floors free of hazards that could embed in their feet, is appropriate to include in package expenditure.
Having your health conditions reflect your needs, as identified in your care plan, allows you as the recipient greater opportunity to have your provider agree to funding expenditure from your home care package.
Is there any cognitive impairment? Does a daily drive or outing help alleviate sundowning? Would a therapeutic doll or pet make a difference to your loved one's mood or decrease their agitation?
A carer to take the person for a drive each day could be funded from the package or reimbursement for a portion of the petrol cost each week. Therapeutic dolls or pets can be purchased from package funding.
A registered nurse can screen for and make the application for the dementia and cognition supplement.
Nursing assessment for continence, changing catheters or skin integrity and wound care.
Allied Health support.
Physiotherapy for management of pain, continence or issues with balance (vestibular practitioners).
Physiotherapists are so specialised now, if you have health issues that would benefit from seeing a physio, and you cannot access this service under any other program, a physio can be paid from you package funding.
Dietician for dietary intolerances, malnourishment or unintended weight loss.
Speech pathology for issues with communication or swallowing.
An assessment with an Occupational Therapist (OT) to review the home and ensure any equipment or modifications are considered, such as grab rails, shower benches or chairs, an over toilet frame, bed stick, mobility aids and any devices to assist in the kitchen, such as a kettle tipper or specialised cutlery and crockery.
Exercise physiology for a personalised program of strength and balance. Is group exercise or one on one appropriate?
Support that might be indicated around the home, including personal care.
Does the older person need assistance to have a shower or manage their medications?
Is the older person able to drive, shop, prepare meals or manage finances independently?
What services are needed to maintain the house (cleaning, gardening, etc)?
Consideration for a fall detecting alarm or a key lock box to enhance safety within the home.
Each person’s needs and goals are different, so one care plan should not be identical to the next.
Remember, the care plan informs what supports and services the older person may receive.
The more comprehensive it is, the more options the older person has in utilising their package funding.
Care planning is something we're passionate about and we work with home care packages providers and recipients of packages to ensure the care and support people receive from their home care package is tailored to their needs.
We're happy to chat with you in our Let's Talk Consultation or you can send us a query via the form below to see if you or your loved one has a care plan that reflects your individual needs.
Thank you for contacting us.
We'll get back to you as soon as possible.
What is the dementia and cognition supplement?
What is My Aged Care?
What's the difference between CHSP and HCP?
At See Me Aged Care Navigators our goal is to support older people who want to live well at home.
Join Our Team
Michelle 0432 995 776
terms & conditions, ©see me aged care navigators 2023.