Writing a good care plan for an individual with a disability involves assessment, collaboration, and close consideration of the person’s needs and preferences. Always rely on a person-centred approach. Here's a step-by-step guide to help you create an effective care plan.
Stage 1 Assessment and Evaluation
-
Meeting
Conduct an in person meeting to learn the client’s physical, cognitive, emotional and social needs. This will involve consulting the individual and their family initially.
-
Paperwork
Bring your Participant Intake Form and Care Plan template with ample room for writing. Bring your Information Consent Form This form will allow you to contact and work together with other supports and therapists with your clients permission.
-
Personal information record
Record your client’s personal details such as name, address, NDIS No., plan dates, plan goals and family member/representative details.
-
Record specific care needs
Record your client’s diagnoses, care alerts, therapists, support coordinators and plan management details.
-
Record strengths and limitations
Identify your client’s strengths, limitations and areas requiring extra assistance or support.
-
Record care goals
Consider what your client’s personal goals, aspirations and preferences are. Examples of personal goals could include going to Zumba classes, eating better or improving mobility.
Stage 2 Communication
- Establish effective communication channels with the client and their representative. How do they prefer to be contacted?
- Encourage open dialogue and allow for multiple feedback methods.
Stage 3 Begin developing your client’s Care Plan
- Write a comprehensive care plan including but not limited to: speech and language, vision and hearing, comprehension, mobility, toileting and incontinence, showering, grooming and personal hygiene, dressing, pressure area and skin care, social and human needs, cultural needs, food allergies and other medical alerts, diet nutrition and liquids, sleep, transport needs, therapies, behaviours, medical support, medications, restrictive practices.
- Each of the above should be broken down into ‘Care Needs’ and ‘Goals’.
- Address potential challenges or barriers (such as communication, transport, mobility, behaviours) and record appropriate solutions on the care plan.
Care needs: Dave is able to use sentences, but his speech is indistinct. Speech therapist recommendation is to encourage use of Ipad assistive device and picture board to communicate.
Goals: Progress in communication skills to aid communication of wants and needs.
- Last but not least, ensure that the person’s rights, choices and preferences are respected.
Stage 4 Safety measures
- Assess potential safety risks and develop strategies to mitigate them and incorporate into the care plan.
- Educate any other supports on your team on safety practices and emergency procedures.
Stage 5 Approvals
- Ensure your client and/or representative reads the draft Care Plan and make adjustments as needed.
- Ask your client to sign the care plan and provide a copy of the document to your client.
- Use the care plan to train any supports under your banner that are working with the client.
Stage 6 Regular Evaluation and Revision
- Schedule 3-6 monthly reviews of the care plan to assess its effectiveness. This is simply contacting the client or their representative and saying hey can we talk about any changes you need done to the care plan. Record your review dates and the outcome on the Care Plan.
- Seek regular feedback from therapists and other supports to identify areas for improvement.
- Update the care plan as needed to reflect changes in the person’s condition, goals, or circumstances.
Record Keeping
- It’s good business practice to record everything! From review phone calls, and meetings to training and provision of documentation to the client. Obviously keep it confidential, but this way you have a super easy referral method if there are questions from the client, supports, or the NDIS.
Remember a good care plan is dynamic and should be regularly reviewed and adjusted to meet the evolving needs of the individual with a disability. Collaboration, flexibility and person-centred approaches are key to developing and implementing an effective care plan.