A care plan is a detailed set of instructions for an individual patient to be followed by health professionals and other staff who take care of them. A care plan typically covers the provision of physical, emotional, social and spiritual support for the patient over a period of time (usually at least 1 year) and may also contain details on financial matters such as the cost of services and the use of community resources.
The main components in care planning are goals, objectives, identification of risk factors in addition to clinical/medical information, health profiling in addition to lifestyle-related information , setting measurable goals, establishing priorities by categorizing goals into short term/long term/key areas, monitoring patient progress with timely and regular updates and modifications to goals, objectives and interventions according to patient responses, caregiver progress with timely and regular updates and modifications of goals, objectives and interventions according to the care given , updating the plan on a timely basis taking into account lab reports/x-ray films/procedures undertaken, consultations received , material resources used (medications, equipment, food) , financial information, contingency planning for emergencies/disasters etc.
A care plan is developed by a coordinated team of health professionals who are involved in providing services to the patient / client / user / family or supporting the same. The team may include psychiatrists, psychologists, social workers, clinical nurse specialists (CNS), nurses, dietary/nutritionists, occupational therapists (OT), physiotherapists (PT) and activity professionals [in rehabilitation medicine].
The contents of a care plan may vary according to the severity and stage of disease or disability and the age and physical/mental/emotional condition of the patient. It should be understood that a small part of the care plan can be filled in by patients themselves with help from caregivers.
If the patient requires immediate surgery or if they are not capable to fill up this form, then family members can fill it up based on their knowledge about the symptoms and medical history of the patient.
Care plans attempt to answer questions such as: “What is wrong with the patient/client?”, “What do we need to do for this patient?” and “How well is the patient doing?”.
The contents of a care plan may vary according to the severity and stage of disease or disability and the age and physical/mental condition of the patient. A physician, in conjunction with input from other members of the team, may prepare a care plan for a patient, typically after the diagnosis of a serious disease. Depending on their training and level of experience, nurses can develop their own plans for a patient’s management or assist in the development by other members of the team. Care planning software is also available to be used as an aid in developing care plans.
A care plan is used by medical professionals (physicians, nurses, technicians etc.) to guide the care of patients throughout their treatment. The patient’s family may also be included in the process so they can help give input on what effects the illness has had on them and what kind of support they will need after discharge from the hospital. Care planning software can be used as an aid in keeping track of the patient’s care plan.