Guide To Creating a Care Plan

1. Guide To Creating a Care Plan For Each Client from now to always.

2. Points to Consider • Identify the primary and any other health concerns for this client. • On what basis did you make this conclusion • Are there gaps in your knowledge about your client? Would other information be useful to determine or clarify the health concern? If yes, would do you need to know to maximize your care plan. • Prioritise your intervention goals to address the health concern/s. • What is his current estimated energy and nutritional intake?

3. Identify any excesses and deficiencies; make recommendations to improve his eating plan to provide a healthy eating plan. • Create a suitable and workable eating plan to address gaps in his current eating plan. • Would you include supplement or other treatment options to facilitate a speedier health change? • If yes, what would you suggest? Indicate the dose, frequency and application method. • What life style changes would you suggest to this client to facilitate health change?

4. How, if anyone might you refer him/them to, to support change or learn new skills to support the changes? • What are the possible and perceived barriers to change? • Outline possible solutions to assist your client achieve an easy transition to a healthier life style. • Indicate how you would include the other family members in the change, noting the children’s ages and their possible reaction to the changes.

5. Create a workable Care Plan • Clearly show your goals, sub goals and priorities for intervention. • Indicate how you would structure the next 3 consultations for your client. • What recommendations are you going to give your client and /or wife? • What resources might you give him/them to help explain the recommendations • How are you going to support him/them through the challenges of change over the following weeks? • What information would you give in each consultation? • How far apart would you space the consultations • What tests might be useful to monitor prescribed changes, and when would you suggest these to be done?

6. Points to Documentation

7. What do you think needs to be addressedAs a class discuss this

8. Information recording • The initial summary – the first time you meet a client a thorough assessment and record of your treatment plan is essential. • This allows other practitioners to pick up where you left of, and to easily remind you what you are going to do. • it is legal document, and so it is vital for it to be clear and fairly structured.

9. It includes: assessment of specific nutritional problem/s; plan of care; implementation of care plan; evaluation of the care plan. • A summary of each point can be recorded in short sentences to create an abstract like overview of the client’s current state of wellbeing. • As a prompt, SOAP can be used to help structure the abstract summary of the client’s visit. This ensures a whole picture of the client is recorded. See hand out to read more detail

10. SOAP • Subjective data: information obtained from the client or client family pertinent to the listed problems recorded. • Their perception of wellbeing, their description of symptoms and concerns. Record in “their words”. • Objective data test results, practitioner observations; anthropometric data, limiting factors.

11. Cont.... • Assessment: the practitioners their interpretation/diagnosis if known, or their impression of the situation and presenting problem/s • Plan: recommendations of care for the client; the interventions & education given, referrals to give the client, futures planned education and intervention strategies.

12. Review Consultations • A similar process is completed at each visit. The focus is on evaluating previous intervention strategies and how the client is integrating them into their lifestyle. • Records: • Progress with strategies, barriers and successes; new or repeated anthrop. results; new or to continue strategy plan, referral network if needed.

13. Letter Writing • When writing to another health professional, in particular the client's doctor, it is important to convey all the relevant information to help them develop a clear picture of the client’s wellbeing and care plan. • It increases the chance of whole being care being provided as all the relevant parties are aware of your involvement and treatment plan.

14. What to write to doctor - steps • Acknowledge and thank the referrer: doctor • State the client’s name, DOB and when they attended your clinic. • The reason why they attended the clinic. • Who else attended the session; the client’s and other’s interpretation of the reason for the visit or health concern. • Your assessment of the client’s presenting health and their reported, dxed problems

15. Cont... • Request or suggested tests to improve Dx and monitoring. • Your and client stated goals. • Client’s previous attempts or changes they have previously made, successful or not. • Assessment of their recorded nutritional intake, deficiencies and excesses in food groups or nutrients; how was this assessed.

16. Cont... • Recommendations and type of education to support this. What has been covered in this meeting and future intervention & education plan to support goals. • Client’s and their sig. other’s understanding, willingness to comply, your anticipated compliance. Acknowledge what might need to change to increase compliance and support.

17. Cont... • Suggestion for further external interventions/assessment. • Review plan – frequency and what changes are expected based on the recommendations your have provided the client. • Thank them for their referral and open the line of communication by offering contact from them.

18. Give to the client • Your client expects you to provide some documents to take home with them. • At least provide a list of intervention strategies you have negotiated with them/provided them. • Support information to explain and aid their understanding of the changes, and strategies of how to make the recommended changes.

19. First Points Appendix E • Important things to consider when meeting a client is to create a comprehensive picture of the health picture the person currently is in. • Subjective Data: This needs to include • The physical – • biochemistry • anthropometrics • Signs, symptoms • Medications, supplements, recreational drugs. • Food choices, preferences, likes, dislikes • Current exercise pattern • Medical history, diseases, symptoms development and change

20. Objective Data • Client concerns, discomforts and view of their health/life situation • Life style choices, include work, play, family, commitments etc – life wheel. • Self perception, self expectations • Goals, hopes and desires. Short and long term. • Your interpretation of the client and how they appear. Psychological and behaviour/verbal comments they provide • Reason for attending • Referral by • doctor • Other medical or allied health professional • Self choice/ referral

21. Assessment • Your assessment from subjective data • Physical and biochemical abnormality if any. • BMI; waist/hip ratio; weight; biochemical alterations; • Nutritional excesses and deficiency • Note lifestyle choices that are contributing current presentation. • Significant phrases and client interpretation of the situation. • Plan • Goals and objectives of how to achieve changes identified and negotiated during consultation • Referrals or other services or organisations that can facilitate negotiated change. • Record of education provided and resources provided. • Frequency of R/v and topics for future education.

22. When not to use best practice principles • Acute surgical and medical • Traumatic injuries or conditions with higher treatment priority • Life threatening situations • Personal or life circumstances • Ability or willingness to comply with treatment • Allergies/sensitivities • Past treatment history • Current conditions/disease state • Current medications/treatments • Contraindications for use of certain percipients and bases

23. Client compliance refers to: • Ability to follow instructions or suggestions • Willingness to follow instructions or suggestions • Discrepancies may include: • Client is unaware of the immediate danger of their condition • Client is over anxious about their condition • Client is unaware of maintaining causes acting on their condition • Practitioner is unaware of some implications of the client’s condition • Practitioner and client have a different view as to what the main problem is

24. Practitioner responsibilities may include: • Isolating the sick person • Notifying doctor about their condition • Appropriate hygienic procedures • Notifying state health authorities of notifiable/communicable disease • Commitment to the treatment plan • Discussing relevant contraindications or potential complications to treatment • Reviewing of treatment plan

25. Client responsibilities may include: • Following instruction/advice during and post treatment • Advising practitioner of any relevant contraindications or potential complications to treatment • Advising practitioner of compliance issues • Commitment to the treatment plan