The RN assigned to open the case will complete the care plan with input from client and family.
The RN will identify goals for provision of care and services and the promotion/maintenance of optimal functioning, to which the employee will be responsible for adhering.
The RN will complete the client data section, which includes demographic data, sensory impairment, infection control issues, psychosocial data, mobility data and safety measures needed.
The RN will include the visit frequency as per the client’s request.
The RN then completes the activity section with client input by marking the frequency of each activity requested, whether the client requires total care or assistance with care and any special instructions for provision of care. Activities include personal care, treatments, nutrition, elimination, exercise and activity and housekeeping. Space is provided for additional activities not listed on the form.
The RN will complete additional special instructions in the sections labeled as such, as necessary for information that may not be captured in the activity section.
The RN will add additional signs and symptoms to document and report to the office at the bottom of each activity box as appropriate.
The RN will sign the care plan with title and date.
The RN will update the care plan as the client’s condition changes but at least every 60 days for home health clients, then will sign and date the bottom of the form as updates are completed.
The original copy of the care plan will be kept in the home care file at the office. The second copy will remain in the client’s home folder for reference.
The first page of the care plan functions as an overview of services provided throughout the duration of services. Pages 2 through 7 of the care plan allow for further description of services listed on page 1.
You can only perform tasks outlined on the plan of care of the client you are assigned to serve. If the client has additional needs, you must promptly notify your Supervisor or the office.