**** CARE PLAN ****
CURRENT ADMISSION: _____________________________________________________________
REVIEW DATE: _____________________ NEXT REVIEW DATE: _______________________
RESIDENT AND/OR SIGNIFICANT OTHERS PRESENT: Resident (name) attended the care plan conference and was an active participant in the details and goal setting.
INTERDISCIPLINARAY TEAM: (check off discipline attending and add name next to discipline)
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Physician __________________________________
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Nurse Practitioner ___________________________
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Social Worker ______________________________
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
MDS Coordinator ___________________________
Nurse _____________________________________
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Dietician __________________________________
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PT _______________________________________
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OT _______________________________________
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Chaplain __________________________________
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Speech/Audiology ___________________________
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Recreation _________________________________
DIAGNOSES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
CATS: (List) _______________________________________________________________________
ADVANCE DIRECTIVE: Resident (name) has an Advanced Directive on File.
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YES
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NO
Resident (name) has a Legal Guardian. His/her name and contact information is: _________________
_________________________________________________________________________________
REASON FOR ADMISSION: (What is the long term or short term reason for admission?)
TREATING SPECIALTY: (If your facility has a treating specialty that relates to reason for admission, list it here.)
LONG TERM GOALS: (What is the resident’s long term goal? What is the interprofessional team’s long term goal for the resident?)
Code Status: (What is the code status for the resident and where can it be found?)
ALLERGIES: (List all medication and food allergies.)
Social History: (Resident’s interview in their own words.)
Psychosocial Wellbeing: (Resident’s interview in their own words. How do they state they are doing in this area? If you do well, you will see improvement in this area from admission to resident’s and staff’s evolution during stay.)
Resident' Goal: (Resident’s goals in relation to psychosocial wellbeing.)
NURSING CONCERN: (Concerns from nursing staff.)
COMMUNICATION/MEMORY: (Resident’s interview. What help’s resident with communication and memory.)
Resident's Goal: (Resident’s personal goals in relation to communication/memory.)
HEARING: (Is this an issue? If so, what is needed to assist in this area?)
VISION: (Does the resident wear contacts or glasses? Are they able to put these on or in independently?)
Month Year Page 1 of 2

MOBILITY: (Both resident and staff input here.)
AMBULATION: ( Both resident and staff input here.)
Resident's Goal: (In relation to ambulation.)
TRANSFER: ( Both resident and staff input here.)
POSITIONING: ( Both resident and staff input here.)
ASSISTIVE DEVICES: (List if any.)
PERSONAL CARE: ( Both resident and staff input here. What does resident like and can staff provide that. For example, does resident want a 30 minute hair conditioner 3 times a week and can facility compromise to providing that once a week?)
ORAL CARE: (Can resident provide their own oral care? Will they need encouragement?)
GROOMING: ( Both resident and staff input here.)
BATHING: (
Both resident and staff input here. What is resident’s preferred routine and what staff assistance is needed to provide that?)
Resident's Goal: (Resident’s personal goals in relation to bathing.)
DRESSING: ( Both resident and staff input here. What is resident’s preferred routine, what do they like to wear and what staff assistance is needed to provide that?)
TOILETING: ( Both resident and staff input here. What is resident’s preferred routine? How often do they move their bowels – daily patterns and what time of day does that usually happen and what staff assistance is needed to provide that assistance?)
COMFORT/PAIN: (Resident self-report.)
SAFETY/FALLS: ( Both resident and staff input here. How safe does the resident feel with staff assistance if that is needed. What is needed to form trust?)
Resident's Goal: (Resident’s personal goals in relation to safety and falls.)
ACTIVITIES: (What does the resident like to do normally? Is this something the staff/facility can provide? What compromises can be made so that activities for the younger adult can be provided?)
Resident's Goal: (Resident’s personal goals in relation to activities. What will they participate in and how many times a day/week?)
NUTRITION: (What does the resident like to eat? Remember that a younger adult will usually like to snack more? What input does the dietitian have in this area to help meet mutual needs? For example, a bariatric resident who needs to be fed may want to have high calorie snacks fed to them every half hour, but the facility cannot provide staffing to do that, nor can the equipment they have handle any weight gain of this resident.)
Chewing problems/swallowing precautions: (List if any.)
Dining area: (Where does this resident want to have their meals? List their preference.)
Eating habits: (How often does the resident want to eat? What time of day/evening do they normally take their meals? Younger adults normally like to sleep later and stay up later than older adults and may not want breakfast at 7am and dinner at 5pm.)
Hydration: (What beverages [non-alcoholic] does the resident like to drink? Most LTC facilities only offer decaffeinated coffee and drinks but younger adults tend to like caffeinated beverages. Do they like water or juices between meals? Is this something you can provide?)
Goals: (Is there a weight gain or loss goal the resident has stated they have for themselves?)
SPIRITUAL CARE: (This is a resident self-resort. What are their spiritual needs and connections? Some may have traditional beliefs while some may have “New-Age” spiritualism? This is something you will have to attempt to support.)
DISCHARGE PLAN: (What are the resident’s goals if any for discharge? Are they realistic? If not, can counseling be provided to help the resident accept the non-reversible situation?)
Month Year Page 2 of 2