A CARE PLAN IS A WRITTEN ASSESSMENT that comprehensively addresses the health status, healthcare needs, and unique preferences of an individual. Care plans are legally required for nursing-home residents and are an effective tool for communication and to align expectations between the individual receiving care, their family, and healthcare providers.
A well written and thorough care plan will include documentation of the following:
• Preferences of the resident, including hobbies, usual activities, bathing, sleeping patterns, socialization, and religious
• Medical diagnoses
• Psychological and intellectual disabilities and developmental diagnoses and history, if applicable
• Health history and physical, including cognitive functioning, sensory and physical impairments, and the risk of falls
• Psychosocial history
• Prescription and over-the-counter medications
• Any other alternative remedies and treatments the resident is taking or receiving
• Nutritional and dietary requirements, food preferences, need for any adaptive equipment, and needs for assistance and supervision of meals
• Height, weight, and history of weight changes
• An assessment that evaluates the resident’s ability to perform activities of daily living
• The resident’s risk of falls
• Vision, dental, and hearing function, including the need for eyeglasses, dentures, or hearing aids. At minimum, the care plan is required to be updated within 14 days of entering a nursing home and every three months. The care plan should be updated every time there is a change in any of the above areas. Care plan updates should include resident input and never be made without the resident being informed. The care plan should be specific and unique to the resident.
The State Long-Term-Care-Ombudsman Program is available to help you understand care plans. Contact us for more information about this or any longterm- care topic. Our services are provided free of charge and can be confidential if desired. We also welcome community members to train and serve as volunteers. In the Toledo area, we serve 17 counties, and can be reached by calling 419-259-2891 or 1-800-542-1874.
