Everything You Need to Include in Individualised Care Plans, Plus Examples

Individualised care plans can help you provide a higher standard of care and support. However, for them to make a real difference, they need to be written and applied correctly.

Keep reading as we explore how to create care plans that will support you and your clients alike. We’ll also provide individualised care plan examples for you to draw inspiration from.

What Is an Individualised Care Plan?

Individualised care plans, or support plans, are legal documents that outline the agreed treatment for each client. They cover both routine and emergency situations, and as such, you might have one or several care plans for each client.

These documents ensure that every team member knows how to care for the client, including when the unexpected happens. In this way, they can improve the quality and consistency of care while ensuring that the client’s needs and wishes are respected.

They are also required by both the Australian Department of Health and the NDIS.

How to Create an Individualised Care Plan? — With Examples

The most important thing when creating an individualised care plan is to involve the client and, if relevant, their loved ones or guardians. Their preferences and goals should inform the actions outlined in the care plan, and their approval of the final document should be obtained.

You should also use clear, specific and objective language. Where possible, give measurable descriptions that avoid ambiguity or misinterpretation. For example, it’s better to say “three times a week” than “regularly”.

Make sure to include the below items in your individualised care plans. Some of them may overlap slightly, so adapt this as needed. 

1. Basic Client Information

  • Medical information

  • Personal routines

  • Demographic data 

For example:

Nicholas is a 72-year-old man with moderate Alzheimer’s. He often forgets appointments as well as whether or not he has paid his bills. His grandchildren visit on Saturday afternoons, but Nicholas doesn’t always remember that they are coming. He also uses a hearing aid. 

2. The Client’s Needs

  • A clear description of the client’s needs 

  • How to support a client with these needs

For example:

Kyoko needs support with food shopping. A care worker will collect Kyoko’s shopping list every Wednesday at 9:45 am and then do her grocery shopping. The care worker will then help Kyoko unpack the shopping.

3. The Client’s Goals

  • What the client’s goals are

  • The actions that will be taken towards these goals

  • Timeframes

For example:

Alex wants to develop better control over their stutter and cluttering so that they have more confidence in social situations and can participate more at school. They want to confidently give a 10-minute presentation in their Spanish class in May. 

Alex will attend weekly speech therapy sessions at 4 pm on Tuesday afternoons and receive exercises to practise at home. They will also attend counselling sessions at 10 am on Saturday mornings to learn coping mechanisms for when their speech impediments make them anxious in social situations or during presentations. 

4. The Client’s Support and/or Care 

  • What support and/or care the client will receive

  • How frequently the client will receive it

  • Who will provide this support and/or care

For example:

Oliver will receive weekly physiotherapy sessions on Mondays at 6 pm from Yousef, along with daily exercises to do at home, for the next three months. Yousef will then evaluate Oliver’s progress and recommend further treatment.

5. Details of Emergency Procedures

  • Likely emergency procedures 

  • The actions staff should take in case of emergency procedures 

For example:

If Diwa has an asthma attack, her main reliever inhaler will be in her handbag. There is also a spare one in the medicine drawer, which is the top drawer to the left of the fridge. She needs to take one puff every thirty seconds. If, after 10 puffs, she is still having an asthma attack, the support worker will call an ambulance.

6. A Record of When the Plan Was Created

  • The date the plan was originally created

  • When the plan was reviewed and/or modified

  • When the plan will next be updated

When and How to Use an Individualised Care Plan?

It doesn’t matter how precise or comprehensive your individualised care plans are if they’re outdated or not being used by your team members. Carers and support workers must read the care plans before their first session with a client. They should also re-read them before additional sessions to refresh their memory.

You should also refer back to the individualised care plan with the client if their situation changes, they express dissatisfaction with their care or support, or they are struggling to meet their goals. Remember, a care plan isn’t just a procedural document. It’s also a way to communicate with clients and provide people-centric care.

Finally, it’s important to review and update care plans regularly with the client and their support workers. At a minimum, this should be done annually.

Individualised Care Plan Management Made Simple

Individualised care plans reduce risk, support your staff and ensure clients’ needs are met. They also give clients a say in their care and can help improve both the consistency and quality of support provided.

Once you’ve got your individualised care plans in place, you’ll find they make a real difference to both your team’s workflow and your clients’ quality of life.

Here at ShiftCare, we believe that you just need the right tools to provide excellent care and support. That’s why our software allows you to upload multiple care plans and share them instantly with the whole team. You can also set care plan expiry dates, complete with automatic notifications, so you’ll never forget to update them. Find out more with a free trial.

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