Writing Your Care Plan.
A statement of something of concern to the resident or the nursing staff or both.
An actual or possible difficulty/limitation/risk resulting from the resident’s illness or
condition, which can be helped, resolved or prevented by nursing intervention.
Medical diagnoses refers to illness, nursing problems focus on the resident’s response to
Problems arise from diseases/illnesses / conditions that the resident has and how these affect the
resident for this domain.
If the resident has no actual or potential problems in this domain, record this under the problem
Goals are statements of what the resident and / or nursing want to achieve.
Goals should be SMART – specific, measurable, achievable, realistic and have a timeframe where
Goals often fall into one of the following categories:
Maintenance: To maintain the resident at their current level of ability/functioning.
Prevention: To prevent/ minimise the likelihood of something happening eg a risk /
deterioration in condition/ability etc.
Palliative: To provide / maintain comfort.
Restorative: To restore /improve ability/condition etc.
If the resident has no actual or potential problems in a particular domain, the goal might be to
maintain their ability /independence in that domain.
The care plan provides information / instructions on how the resident is cared for on a day to day basis
and should include:
What the resident can do.
What assistance, if any the resident needs in this domain.
Likes / dislikes/ preferences relevant to this domain.
Aids / equipment used and how specific to this domain.
Involvement of other healthcare professionals and implications for care.
Specific interventions to be carried out to address problems / risks related to this domain.
Remember, even, if the resident has no actual or potential problems in a particular domain, there may
be information that staff need to know about any preferences, abilities etc. as and if relevant to the
If the information is already recorded in another domain, there is no need to duplicate, just refer the
reader to the other domain(s).
Example of Problem (s): Mary is unable to wash and dress independently due to right sided weakness resulting from her CVA.
Goals: To maintain Mary’s Personal Hygiene.
Care Plan Prompts.
Describe what difficulties the resident may have when washing and dressing.
Identify what the resident can do.
Identify and document any assistance the resident may require with washing, bathing, showering and dressing e.g. prompting, supervision, assistance of one person, assistance of two people.
Document the resident preferences / likes / dislikes for washing and dressings e.g. shower, bath, toiletries preferred, hair style etc.
If the resident has a bath/shower, document how often this occurs and who makes this decision.
If the resident requires assistance with his/her hair, document the level of assistance and how hair cutting is managed.
If the resident requires assistance with finger and toe nails, document how these needs are met.
Andrea’s tip: The care needs to address oral and dental care can be addressed in Oral and Dental Domain – you can refer to the need and state that it is addressed under Oral and Dental Domain.