GUIDELINES: GOAL BASED ASSESSMENT TOOL, CARE & TREATMENT PLANS / Date July 2014
HACC NURSING SERVICES
BARWON SOUTH-WESTERN REGION
GOAL ORIENTED ASSESSMENT TOOL / CARE PLAN & TREATMENT PLAN
VERSION: DATED July2014
Insert agency name here
Thank you for your interest in using these tools! If you require further assistance please contact your Active Service Model Industry Consultant.
Agencies providing HACC funded Nursing Services in the Barwon South Western region collaborated on improved approaches to Assessment and Care Planning – particularly focusing on approaches to the Active Service Model, which emphasisesthat:
People want to remain autonomous, not reliant on us as nursing experts
People have the potential to improve their capacity, even if that capacity is limited...there is still potential for gain
People’s needs should be viewed in a holistic way, not as a bunch of medical problems
Our HACC services are organised around the person and carer, we don’t simply ‘slot’ the person into our service
A person’s needs are best met where there is a strong partnership and collaborative working arrangements between the person, carers, ourselves and other agencies.
The tools have been developed for use as a paper based tool and as an interactive word document.
The tools promote a conversational, person centred approach that focuses on how the person is managing, their strengths, interests and motivation to improve their capacity to self-manage.The structure of the tools
Each section heading in the tool is displayed in a black panel with prompts to assist with identifying relevant information. A ‘preparation’ panel suggests how to go about gathering as much information about the client before and during the assessment. A ‘nil problems / Not Applicable’ tick box at the beginning of each section heading is intended to aid navigation through the tool.
There are three linked tools:
The tools and these guidelines do not replace your professional clinical judgement. Please review these guidelines to ensure all stages of the process are completed effectively.
GUIDELINE ONE: ASSESSMENT TOOL
The purpose of the assessment tool is twofold:
- To complete a clinical assessment for nursing services
- To identify the client’s issues that lead to a set of goals for the client and our service to improve their health and wellbeing
The assessment process is in three stages:1 / Preparation / Once a referral has been received, seek all available information including:
SCTT tool information from referrer
Living At Home Assessment (LAHA) from Council
Medical and other records
2 / Home visit(s) / The interview to complete the assessment form is critical to establishing the strengths of the person (what works for them), their future goals (what else would work) and our role as a service (how can we work together). Allow adequate time to complete the interview – it may be advisable to complete the interview over a number of visits.
3 / Recording / The interview form can be filled in by hand during the interview and typed up and saved into your client information management system or using an ipad or tablet typed directly into the interactive word document.
Agency specific requirements:
Most of the questions in the assessment form are straight forward and self-explanatory. The following tools are required by our agency if, in your clinical judgement, a detailed assessment is required:Section of the assessment / Additional tools and application
Wellbeing, living and lifestyle / Carer Strain Scale
Self care / activities of daily living
Current visiting services
Cardio vascular and respiratory
Endocrine / diabetes
Cognition, dementia, delirium. Depression
Other lifestyle issues: alcohol
Other lifestyle issues: smoking
Other lifestyle issues: other drugs
Other lifestyle issues: gambling
Insert other agency specific instructions / guidance here
GUIDELINE TWO: CARE PLAN
The care plan belongs to the client, not us. Please use language that places the person at the centre of the plan.
As the plan template states: “The purpose of this District Nursing Service care plan is to record our agreement to actions that will support your health and wellbeing goals.”
The ‘approaches’ or goals within the care plan should have arisen during the clinical assessment.
The ‘action’ should, wherever possible, focus on the action that the person can take to retain / restore independence and autonomy.
The actions for other people, eg making a referral, need to be written in the language of the person. Ensure that the action we will take to provide treatment is outlined.
Ensure consent to received (either written or verbal) to share the information within the care plan.
Ensure adequate follow up – that all parties receive a copy of the plan.
A review of the care plan must be scheduled.
GUIDELINE THREE TREATMENT PLAN
The treatment plan outlines the action that our agency will take to treat the person. Note all issues that will assist other staff in the delivery of care.
The purpose of the treatment plan is to accurately record the agreed services to be provided by the nursing service.Insert agency name here / Page 1