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Setting Up a Care Plan

By , Contributing Writers
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A plan of care is a daily record of the care and treatment a person needs after a hospital stay. The plan helps you and the person in your care with caregiving tasks.

When a person leaves a hospital, the discharge planner provides the caregiver with a copy of the doctor's orders and a brief set of instructions for care. The discharge planner also works with a home health care agency to send a nurse, The nurse will evaluate the patient's needs for equipment, personal care, help with shots or medication, etc. The nurse will also work with the entire health care team (including you as the caregiver, a physical therapist, and other specialists) to develop a detailed plan of care.

The plan of care includes the following information:

  • diagnosis (the nature of the disease)
  • medications
  • functional limitations (what the person can and cannot do)
  • a list of equipment needed
  • special diet
  • detailed care instructions and comments
  • services the home health care agency provides

The information is presented in a certain order so that the process of care is repeated over and over until it becomes routine. When the plan is kept up to date, it provides a clear record of events that helps solve problems and avoid them.

With a plan, you don't have to rely on your memory. It also allows another person to take over respite care or take your place entirely without too much trouble.

Some of the things you may have to watch and record are

  • skin color, warmth, and tone (dryness, firmness, etc.)
  • pressure areas where bedsores can develop
  • breathing, temperature, pulse, and blood pressure
  • circulation (dark red or blue spots on the legs or feet)
  • fingernails and toenails (any unusual conditions)
  • mobility (ability to move around)
  • puffiness around the eyes and cheeks, swelling of the hands and ankles
  • appetite
  • body posture (relaxed, twisted, or stiff)
  • bowel and bladder function (unusual changes)

Recording the Plan of Care

Use a loose-leaf notebook to record the plan of care. Put the doctor's instructions on the inside front cover (always keep the originals). Include in the notebook the types of forms that appear in the following pages of this chapter. These pages should be three-hole punched.

After using your plan of care for one week, make changes as needed and continue to do so as the person's needs change. Always do what works for you and the person in your care. Use notes, pictures, or anything else to describe your responsibilities. Also, use black ink, not pencil, to keep a permanent record.