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See
DH Special Services Independent Study
Documentation
Techniques for the Activity and Recreation Professional
NCCAP approved 10.5 contact hours
The care plan is a written, systematic approach
for the team to provide and deliver individualized care and
services.
Interdisciplinary care planning follows a
five step process:
Assessment
Preparatory work for
the care plan begins as soon as the resident/client is admitted.
The initial assessment collects data that will be used in the
care plan. The assessment seeks information regarding the resident/client's
needs and problems which are used within the care plan.
The MDS is a screening tool, utilized in long term care, which assists
the health care professional in identifying problems, needs
and strengths. The activity assessment should support data noted
within the MDS
 Problem
& Need Identification
When noting problems
or needs within the care plan, they should be stated in clear,
simple terms.
Problems can be cognitive, physical or psycho-social deficit
which is causing the resident distress.
A need is something required, useful or desirable for the mental,
physical, emotional, social and spiritual well being of the
individual.
The activity professional
should consider causal factors when identifying problems/needs
for the resident. In many cases, difficulties in activity participation
or socialization is related to a primary problem such as cognitive
loss or a physical limitation.
Development of Goals
and Interventions
Goals should focus
on a resident/client achievement such as a task, response, behavior,
action the resident/client will do. Goals should be measurable,
specific and realistic.
Interventions are the actions the staff will take to assist or guide the resident
to achieve their goal. The interventions need to be individualized
to the resident, focusing on past and current interests. Specific
adaptations and approaches are encouraged.
Implementation
Once written into the care plan, the activity
professional is responsible to ensure implementation. Communication
and monitoring systems (such as departmental meetings and attendance
records) can be utilized to ensure consistent implementation.
Evaluation
Periodically, the care plan and implementation
of interventions needs to be reviewed. In accordance with Federal
requirements, a quarterly time frame is generally practiced.
The purpose of the evaluation is to review how the resident/client is responding to the interventions,
are they successful or have barriers been encountered. The care
plan should be updated accordingly.
The care planning process is a continuous
process
and if utilized properly, can be an effective tool
for the care givers.
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