The care planning process in long term care can seem like a daunting task as the care plans must be individualized and follow state and federal regulations as well as current standards of practice but also be user friendly. The more the individual is kept in focus, however, the easier the mission becomes. Care plans are the action plan created by residents and staff on what will be done to get the resident from where they are to where they want to be.
Let’s get some mistakes to avoid out of the way first. Don’t create the care plan independently without including the resident. Sometimes the care plans are created ABOUT the resident but not WITH the resident which may not reflect their goals or wishes. These care plans are created because the regulations say so and then are forgotten about until the next care plan meeting. Think of care plans as an action plan that involves the resident and is referred to frequently to check progress and adjusted as needed in order to meet goals.
There are three ways or styles in writing care plans. They can be “resident planned” which sounds like the resident wrote it, ex. “I would like smaller portioned meals”. They can be “PES-like”, using Problem-Etiology-Signs/Symptoms from the Nutrition Care Process. They can also be “resident stated” using the term resident or stated name, ex. “Mrs. Smith is overweight and wants to lose weight so walking is easier for her.”
Once the style in which the care plan is written is established, then identify problems/needs or strengths. This comes from the assessment which includes record review, observation, interview, MDS and CAA. Check to see if there is a hospital care plan available to review as the goals from this might need to be continued. Identify resident preferences which is their self-assessment of problem/need/strength.
Next, develop goals which need to be measureable, reasonable and attainable. We need to offer suggestions on how to meet goals and provide education. Find out if they have a time frame in mind to achieve the goal. It’s important to note if the resident is committed to working towards the goal. Remember to keep the problems and goals related.
Interventions are the things that are going to happen in order to meet the goal. In other words, they reflect the problem and help achieve the goal. If the resident is capable of or committed to working toward the goal, include the resident’s actions in the care plan approach as well as the progress note and/or assessment. If the resident is not committed to working toward the goal but still wants the goal, include this in care plan approach (education) and in progress note and/or assessment.
Remember that the care plan should be updated as needed. Update as conditions change, as goals are met, as interventions are determined to be ineffective, or as specific treatable causes of nutrition- related problems (anorexia, impaired chewing, etc.) are identified. If nutritional goals are not achieved, different or additional pertinent approaches are considered and implemented as indicated.
Finally, documentation shows you are “living” the care plan. Starting with the initial care plan documentation, use the nutrition assessment and resident/family interview as a basis for the care plan and write the care plan using the nutrition diagnosis as a guide. Then follow up with documentation in- between quarterlies and at the quarterly to explain where the resident is regarding the nutrition goal and address any changes in the plan.