HOW TO WRITE CARE PLANS FOR NURSING HOMES

WHAT A CARE PLAN IS:

Federal law requires that nursing homes develop care plans for all residents. A care plan, which can
address both medical and nonmedical issues, outlines how the nursing home staff will help a resident,
listing what each staff member will do and when it will happen. For example, a care plan might list that
a nursing home resident needs to build strength and maintain muscle by walking a certain distance
each day. A good care plan facilitates communication between nursing home staff and ensures that
residents' needs are met. Someone unfamiliar with the resident should be able to pick up the nursing
home care plan and know how to care for the resident

INSTRUCTIONS:

1
Complete a comprehensive assessment of the resident's physical, social, emotional, and mental
needs. Each nursing home may have a set of standard protocols to use when assessing a
resident's needs.

2
Assemble a Care Plan Team that will work together to develop the Care Plan. The Care Plan Team
may include nursing home staff, the resident's physician, the resident's family, and the resident.

3
Develop a list of the resident's problems. The problem list can include medical diagnoses, physical
weaknesses, family problems, social withdrawal, and any other items affecting the resident's health
and well-being.

4
For each problem listed, determine if it can get better with appropriate steps and action, is unlikely
to improve but can be maintained, or is unlikely to improve and will probably continue to deteriorate.

5
For each problem that can be improved, develop specific, measurable, and attainable goals for
improving the problem.
For each problem that can be maintained, develop specific, measurable, and attainable goals
designed to keep the problem from getting worse or from developing complications.For each
problem that will probably continue to deteriorate, develop specific, measurable, and attainable
goals that will delay or slow deterioration and that will provide the resident with optimal comfort
and quality of life.
 6
Develop interventions and plans for achieving each goal. The interventions and plans must
incorporate physician orders, facility policies, and accepted standards of care. The resident and
the resident's family may also provide input into the interventions and plans.

TIPS AND WARNINGS:

A facility should complete an initial nursing home care plan within 24 hours of a resident's
admittance to the nursing home. A full care plan should be in place within 21 days.

Both nursing home residents and their families can participate in meetings to develop and
review nursing home care plans

Nursing home care plans need to be reviewed and modified as the resident's needs change,
or at least every year.