Service Users Name:

Care Plan

The Care Plan shows who is involved in a Service User’s care, the main focus; agreed goals developed together, planned actions and who is responsible for each action.


Service User

Name:

Date of Birth: / / Sex:

or affix label here

Consent Checklist

Before developing this plan, ensure consent to share information has been obtained

P

Participants Involved in Care

List known persons currently contributing to the Service User’s care, including the individual and the carer/advocate and the key worker /care plan coordinator/facilitator (e.g. GP, health/community care providers, substitute decision maker, family members, volunteers or friends who provide assistance). Attach sheet to specify any additional persons.

Name / Role or area of support / Contact phone number/s / Other relevant contact details (e.g. agency, email) / Participant in planning process (yes/no) / Copy of plan provided (yes/no)
Service User
Carer
Key Worker

Emergency contacts and plan if client does not respond to scheduled visit

Expected Outcome: A risk management approach will be taken prioritising the client’s safety, should there be an emergency or the client does not respond to a scheduled home visit:

1st Contact: ……………………………………………………………Relationship: …………………………………………….

2nd Contact: ……………………………………………………………Relationship: ……………………………………………

Specific instructions:

This information collected by: CP Page 1 of 3

Name: Position/Agency:

Sign: Date: / / Contact number:

The Person’s Story and Reason for the Plan

Care Plan

Opportunities
(list in order of priority) / Agreed goal (measurable) / Action/s to be taken by whom / Target date
1 Pain in the knees – need to investigate cause and treatment options / 1.1 Aunty would like to find out causes of her knee pain by the end of March / Action: Arrange a visit to the GP on Thursday at 10am
Who: Aunt: HACC Coordinator or Aboriginal worker will provide information to the GP with Aunty’s consent / Tuesday
1.2 Seek advice about treatment and/or pain relief for the knee / Action: Following the GP visit, and if appropriate, arrange an appointment with the physiotherapist at the community health centre
Who: Aunty, Aboriginal worker, HACC Coordinator / Date / time
2 / 2.1
2.2
3 / 3.1
3.2
4 / 4.1
4.2

Plan developed: / / Target Review date: / / Case Conference: Yes □ No □

Service User understands and agrees to this plan: Yes □ No □

Signature if applicable: Date: / / Attach more sheets as necessary.

This information collected by: CP Page 2 of 3

Name: Position/Agency:

Sign: Date / / Contact number:

Review of Care Plan

For use when the Care Plan is reviewed. It shows the outcomes/progress of agreed goals and planned actions

Opportunity Goal Reference (Refer to Care Plan): / Progress / Source of information
Pain in the knees / Aunty has had appointment with GP and understands that she is to participate in gentle exercises; she has started physiotherapy sessions. / Aunty; Aboriginal worker

Supporting Documentation including Alerts / Key Considerations

This may include social profile, assessments, service plans, support plans, GP plans, advance care plans, emergency management plans, screening or risk alerts. List appropriate documents and source or location.

This information collected by: CP Page 3 of 3

Name: Position/Agency:

Sign: Date: / / Contact number: