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

MDT Outcome Interventions (actions) Nurses/ OTs Interventions (actions) Social Workers interventions (actions) Medics


ES Recovery

Elements of a care plan

• • • Are our care plans recovery focussed?


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 it?) (how are we going to achieve


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


of symptoms

When considering outcomes think S.M.A.R.T


pecific •


easurable • •




ealistic •



When considering outcomes think S.M.A.R.T

• • 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.