MDS Alert

Use these steps to build a comprehensive care plan that puts residents’ needs first.

First thing’s first
Gather information about the resident necessary to writing your care plan and understanding any issues.

• Explore and collect any and all information that will provide helpful context about the resident. Think in terms of past, present, and future when you evaluate their conditions, needs, risks, problems, and prognosis.
• Assess: Interview the resident to determine her personal history, look over her clinical record, perform a physical examination.

Define the problem
Give particular attention to a resident’s problems, risks, and issues.

• Take a holistic look at the resident: Explore the resident’s current situation. Look for the cause and effects for conditions, illnesses, how the resident behaves.
• Make sure you fully understand and can comfortably express the resident’s physical, psychosocial, and functional strengths — and any problems, needs, deficits, and concerns, too.
• Learn and state any significant risk factors.

Follow the dominoes
How does a physical, functional or psychosocial strength or issue affect or compound other issues and consequences?

• Think of this as diagnosis: What are the causes of the resident’s current status, particularly the challenges he might face in terms of disabilities, impairments, or further risks?
• Figure out which specific evaluations or diagnostic tests the resident might need.
• Picture the resident’s physical signs and symptoms, the clinical diagnoses and test results, and the everyday impairments and challenges or disabilities as different locations of a spider’s web. How are they all connected?
• How would addressing any known or determined causes of issues affect the resident?

Determine goals and objectives
Think of this as the backbone of your care plan and consider the following questions and thought processes.

• How will particular steps or interventions affect the resident’s daily life?
• Why does the resident require this particular type of care, and how will team members evaluate whether the purpose — meeting the goals or objectives — is met?
• If you need to address a particular illness or dysfunction, what’s the prognosis?

Choose the path forward — make the plan
Figure out which interventions or treatments or approaches are going to have the best effect on the resident’s physical, functional, and psychosocial well-being and reality.

• Determine the relationship between specific symptoms and particular interventions
• Be specific in your reasoning: how exactly will interventions address the underlying or obvious causes of a resident’s condition? How will they help the resident reach her goals?
• Identify the benefits and risks of each intervention

Monitor care plan progress
Keep an eye on how the resident is moving toward his goals, and be flexible in adapting any interventions to work better.

• Evaluate and record the resident’s response to all interventions and treatments
• Figure out if anything is halting progress to goal achievement
• Adjust the prognosis, if necessary, to keep accurate
• Identify when objectives/goals are met and resident can be discharged, transferred, to qualify for a different level of care

Extra credit: Don’t forget to incorporate these important facets to ensure an individualized, comprehensive care plan.

Although CMS doesn’t require staff to follow a specific format, there are particular elements that all plans should cover. Maximize the specificity of each resident’s plans by including these particulars when you’re writing, provided by the University of Missouri Sinclair School of Nursing:

• Cultural preferences
• Spiritual preferences
• Dietary preferences
• Sleep/natural wakening routine practices
• Activity preferences
• Clinical practices, including pain management

And don’t forget the toileting program, if applicable. (See MDS Alert Volume 15 Number 8 for tips on writing and implementing a specific toileting program trial plan.)

To really individualize your care plans and make sure they are laser-focused on residents’ well-being and perspectives, keep these questions in mind as you formulate the plan, suggests Vanessa emm, aCC/eDU, aC-BC, CDP, of tagg emm Consulting in Henderson, Nevada:

• What’s important to me?
• What would I want people to know about me?
• What would my expectations be?
• What should I expect?
• What if my voice isn’t heard?
• Will people understand me?
• Will I be happy?