Care Planning Tutorial
Principles of Care Planning
Peter Graham: Senior Nurse
Care Planning

How many care plans?
Care plan v’s Action/intervention plan

Assessment
One Care Plan
MDT
Outcome
Interventions Interventions interventions
(actions)
Nurses/ OTs
(actions)
Social Workers
(actions)
Medics

Collaboration
ES
Recovery

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?)

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

When considering outcomes think
S.M.A.R.T
• S pecific
• M easurable
• A chievable
• R ealistic
• T imed

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.

Questions