What is a Care plan?
A care plan is a documented guide which outlines the assessed health and social needs of your client and the ways on how you can support them. It may be written in hard copy or provided on soft copy through your computer.
A care plan helps to maximize the mental and physical well-being of your client while under your care. It provides direction for you as a caregiver and a way to communicate to all those involved in the clients care—such as their family, significant other, registered nurse, medical practitioner, social worker and others. The care plan can also serve as a record of care that you provided.
As a caregiver at home, it is essential that you use a care plan when working with a client. This is will help you manage and guide your client’s meals, health activities and exercise.
Having said that, what does a care plan contain?
What are the Sections of a Care Plan?
A care plan has many sections to ensure that we look into the whole aspect of the client’s well-being.
Patient Summary
The patient summary part of a care plan introduces you to the client and has basic information on what you must know about them. This includes their name, age, developmental level, ethnic & religious beliefs, support system and contact information of significant others. It also contains health indicators like height, weight, vital signs, medications and therapies. There is also a summary of the client’s history including any allergies.
Patient Health Concerns
The patient health concerns part of a care plan outlines any current problems in your client’s health. These can be listed as general health behaviors, symptoms, concerns or any social and environmental factors that could have impact on their current state of health.
Patient Goals
The patient goals part of a care plan is used to appraise the client’s progress. This gives direction to the care plan and shows the first sign of what path the client is taking in order to control their health. A care plan distinctively makes up some long- term goals and a few smaller short-term goals.
Sometimes your goals could be related to patient nutrition and exercise.
Patient Nutrition
The patient nutrition part of a care plan is food related like meals and what the client is eating. In this section, you might see dietary restrictions or any chronic conditions or symptoms that your client may have.
Patient Exercise
A patient exercise part of a care plan outlines the recommended activities or exercise regimen for the client. This is especially important for clients with lifestyle conditions such as high blood pressure, high cholesterol and diabetes.
Now that we have learned about the sections of your care plan, let us remember that a care plan can also serve as a record of care that you have provided. Thus you need to do observing, reporting and documenting properly.
How to Do Proper Observation, Reporting & Documentation?
The three essential responsibilities of a caregiver are observing, reporting and documenting. The purpose of this is to communicate status updates or any changes that are happening with your client and/or their significant others. Remember to report and document only the information that you personally saw and did yourself. This will ensure the accuracy of the data you are reporting.
Observation and Monitoring
- Recognize changes in daily routine, appearance, mood or anything that may seem different to you.
- Use all your senses when observing—sight, smell, sound & touch. Noting for signs that the patient is in pain like facial grimacing.
- Ask questions and actively listen to their answers to observe if there are changes in their response.
- Recognize changes in physical health by looking into adjustments in their physical body example a runny nose or presence of skin rashes.
- Recognize changes in mental or emotional status. Such as if the client appears more or may be less active than his/her usual self.
- Recognize changes in home environment. Such as a shift in cleanliness of the house.
Documentation
- It is a record of what was done and can be used for the appraisal of other health care team members.
- Write facts and observations, not opinions, so be objective in taking notes.
- Be mindful to state what “exactly” happened.
- These are the things to avoid in documentation:
- Avoid giving opinion—only report and document the information that you did or saw yourself.
- Avoid waiting until the end of your shift to document the activities that happened within the day—real time documentation is important so as not to forget the details of the information that needs to be reported.
- Remember the following when documenting status updates:
- Write the activities throughout the day as they occur.
- Note meals or appetite, if food was eaten or not eaten.
- Note any medications or drugs taken
- Use precise quotes from the client when they are communicating discomfort or pain.
- Record crucial telephone calls.
- Be specific and accurate with what you document
- Write in a neat manner so that others can easily read your notes
- Check that your spelling is correct.
- Make it a habit to proof read your written documentation
Reporting
- The communication of observations and actions verbally.
- Reports can be through a phone call or in person communication
- Write a written report within the care plan
Your clients are individuals with a set of values and beliefs that may be different from yours. So it is essential that you are respectful and to understand their cultural and spiritual practices.
How to Manage Cultural & Spiritual Differences on The Job?
Never Ignore or Belittle the Beliefs of your Clients
Always approach differences in beliefs with understanding even if those beliefs are directly contradictory to yours.
Be Kind & Respectful
As a caregiver, you will encounter so many different types and classes of people. It is crucial that you handle these differences with kindness & respect.
Be Open- Minded
Cultural beliefs are held dearly by your client and it is important to them. Reverse the scenario and think if it were you, Wouldn’t you like people to be open minded to your beliefs as well?
Listen to their concerns with an open mind and offer to explain any potential misunderstandings.
Work with your Clients Religious Beliefs, Not Around Them
Remember that their beliefs make up who they are and it is a part of what we care for. Religious and cultural beliefs are protected by law. There may be legal consequences if they are not safeguarded.
So are you now more attuned to your role as a caregiver? The next module will teach you the fundamentals of senior living caregiving.