Rating Your Care Planning
Rate your care plans against the 10 most common problems using a 5 point scale from 1- 5; where 1 = Not done at all and 5 = Consistently Done Well.
# / Problem Description / Rating between 1 - 5
1 / Assessment tools linking with Care plans.
2 / Care plans are not goal orientated
3 / Generic care plan templates don’t always allow for individualisation
4 / Input from resident and family /whanau or significant other
5 / Interventions that lack depth or demonstrate support needed
6 / Changes in health status are not reflected in care plans
7 / Evaluations do not link to the goals, or interventions
8 / Changes to care plans
9 / Care plans lack a multi disciplinary approach
10 / Timeframes are not maintained
ADD UP YOUR TOTAL SCORE
Total Score Action Plan
Score / Recommendation
< 30 / Take action NOW - review and update your care plans
31 - 40 / Next opportunity -- review your care plans for “doing the right things right”
41 - 50 / Well done – aim for ongoing reviews of care plans, goals and objectives (perhaps with multi-D, resident and family involvement)
My very next action is to:
______/ The 10 Most Common Problems
With Care Plans in Aged Care
(Oct 2014)

Introduction: Care plans have many titles including Lifestyle plans, and support plans. Whatever the name the purpose is the same, to identify an individualised plan of goals and care interventions for each resident. From our experience in working with aged care services and reviewing many care plans/lifestyle plans we have identified the ten most common problems with care plans (in aged care).
Common Problem #1) Assessment tools linking with Care plans. Assessment tools often cover a large scope and thorough tools identify medical problem, ADL’s, and portray a holistic picture that covers physical, social, emotional, spiritual, and cultural needs. Other assessment tools used identify risks, such as falls risk, pain, pressure area, nutrition, continence and challenging behaviour. However, although the data gathered at assessment is comprehensive, often assessment and care planning templates don’t align and therefore not all relevant detail gathered at assessment is transferred into the care plan.
Common Problem #2) Care plans are not goal orientated. There are many care plan templates in use. Generally most include a heading for key ADL’s such as mobility, hygiene and grooming etc. Care plans should be resident-goal focused. For e.g.: ‘Mobility’ could read ‘Mrs A will continue to independently mobilise safely with her walking stick’.
Common Problem #3) Lack of individualisation. Many care plan templates generic and often takes away the individualised resident-focused plan that differentiates one resident from another. Care plans should include evidence of resident wishes and detail interventions specific to each resident (including interventions that consider medical issues).
Common Problem #4) Input from resident and family /whanau or significant other. There is often lack of documented evidence that care plans have been developed and reviewed with the input of the resident and family/whanau. Care plans should document who was involved in completing the care plan. As a resident focused care plan this should not just be the registered nurse.
Common Problem #5) Interventions that lack depth or demonstrate support needed. The link between assessments, goals and interventions cannot be stressed enough. Interventions should provide enough detail that all staff members (including an agency nurse) are aware of how much support or interventions a resident requires. Interventions should also be documented for the specific staff / Common Problem #6) Changes in health status are not reflected in care plans. Changes in health status are often documented in progress notes but not always documented on short term care plans or updated in long term care plans. Long term care plans should regularly be updated to reflect changes, short term care plans are a useful way to reflect short term changes that resolve problems such as infections, wounds etc.
Common Problem #7) Evaluations do not link to the goals, or interventions. Written evaluations are often completed, but they may not have fully reviewed and documented progress to meeting the identified goals. As above, long term care plans are not always updated following the care plan review. Assessment tools are not often reviewed and utilised when there is a change in health status; ie: falls risk
Common Problem #8) Changes to care plans are not signed/dated. When care plans are updated due to changes in health status or following a care plan evaluation these should be signed and dated. Interventions that are not current anymore, should have a line through them and signed and dated.
Common Problem #9) Care plans lack a multi disciplinary approach. In many services where a multi disciplinary approach and input from allied staff such as Physiotherapists, Activity therapist, Occupational therapists, Dietitian occurs; resident files include separate assessments and separate plans and thus, the overall care plan should be more integrated.
Common Problem #10) Timeframes are not maintained. Contractual timeframe requirements around developing the initial care plan and completion of the long term care plan should be documented in policy and procedure. Timeframes are often not adhered to including the frequency of care plan evaluation.
Conclusion: I’m sure that you or your organisation has considered many of those listed above. Wouldn’t it be great to address those 10 most common problems; (this could also be addressed through your internal audit system) and anymore obstacles or concerns that you may have around care planning and learn to implement a client-focused care plan in your organisation that achieves its purpose?
Turn over to rate your care planning