There are many different kinds of care plans in use across health care in the UK, but each of them has the same three purposes:
- to ensure that the patient/client gets the same care regardless of which members of staff are on duty
- to ensure that the care given is recorded
- to support the patient/client to identify, manage and, hopefully, solve his or her problems.
The care plan is a written document (either electronic or paper-based) that is used and altered constantly throughout the day. It’s based on a ‘template’ which defines the areas the care plan covers. Some templates are very simple and focus on the essentials of care – nutrition, mobility, sleeping, positioning, oral care and personal hygiene, for instance – while others can be very detailed and might include sections on issues like falls prevention, psychological needs, recording of clinical signs, communication and information, and sexuality.
An individual care plan is prepared for each patient/client. Wherever possible, the care plan is developed with the patient/client, rather than for the patient/client.
You’ll be expected to read and use care plans to guide your practice with individual patients/clients, so it’s a good idea to get to know what kind of information they contain in your area. It’s also a good idea to get to know who in your team is responsible for keeping the care plans up to date – sometimes this will be the responsibility of all team members and sometimes only designated people can make entries to the care plan. Your level of involvement will vary from area to area, so ask about what is expected of you.
Generally, the rules that govern record-keeping and confidentiality and consent also apply to care planning. You might remember from our discussion of those issues that abbreviations and other terms that might be confusing can be used in health care records – if you come across anything in a care plan that you don’t understand, make sure you ask a registered member of staff to explain its meaning.