Care Planning Tutorial - Mersey Care NHS Trust


Care Planning Tutorial

Principles of Care Planning

Peter Graham: Senior Nurse

Care Planning

How many care plans?

Care plan v’s Action/intervention plan


One Care Plan



Interventions Interventions interventions


Nurses/ OTs


Social Workers






Elements of a care plan

• Are our care plans recovery focussed?

• Language!

• Issue/ Problem /need….what is your problem v’s how do you usually cope with your problem. Where do we record strengths?

Elements of a care plan

• Goal/Outcome (what do you want to achieve?)

• The outcome is usually not considered fully and is the hardest thing to articulate: road map analogy

• A lack of a shared outcome = dissatisfaction with care

• Interventions (how are we going to achieve it?)


Remember any action/intervention is designed to remove or reduce the negative IMPACT of symptoms

When considering outcomes think


• S pecific

• M easurable

• A chievable

• R ealistic

• T imed

When considering outcomes think


• Are your goals/outcomes SMART?

• How many of your care plans contain the goal of “discharge to the community functioning at the optimum level with the appropriate package of care in place”?

Last admission: things to consider

• Think about the last person you admitted

• Did you know what the purpose of admission was?

• Did you see the assessment?

• Do you know what needs to happen to discharge them? (our outcome)

• Do you know what the person wants from the admission? (their outcome)

Last admission: things to consider

• The outcome is probably the hardest thing to articulate

• What involvement did they have in drawing up

THEIR care plan?

• …does a signature or a ticked box indicate participation?

• Has the care plan been taken into the ward round/MDT meeting?

• How does this care plan fit in with the overall plan of care?

Why have a care plan?

• One person’s experience of the care plan

The first care plan I was given I did not see for six months, I was too unwell, my wife and family saw it, it helped them to understand my illness, and understand that there was not a quick fix. It would be a long journey. As I made progress I became more involved in the care plan and contributed more to the conversations with my

CPN and psychiatrist, that is where I am now.