Transcript Planning Care in the Community

Stake Holders:
Planning Care in the Community
The Glamorgan Spring Bay Community Nursing Team.
The Glamorgan Spring Bay Community Nursing
team met in November 2011 with Clinical Nurse
Educator, Elaine Hosken, to discuss client
centeredness and how we currently form care
plans.
We needed a care planning tool
which was suitable for use within
the context of community nursing.
Client Centered Care Planning
An approach to care that consciously
adopts the individual’s perspective...
(World Health Organisation, 2004).
Plan
Physical
psychological
spiritual
Family
Friends
Culture
Evaluate
Community
Location
Context
Beliefs
Values
Likes & Dislikes
The Glamorgan Spring Bay Community Nursing Service team members.
Elaine Hosken - Clinical Nurse Educator - Professional development.
The Spring Bay Community and Health Centre.
The Department of Health and Human Services.
Objectives
Where it started
Assess
Clients, their Families and Carers
Implement
Claire Warren, 2013.
We needed a care planning tool that:
• Involved the client, family and carers in
decisions about their care.
• Provided effective, continuing care and
communication without repetition.
• Fulfilled professional and legal documentation
requirements.
• Fulfilled regulatory/accreditation standards.
• Was simple to use.
The Concern Index
The ‘Concern Index’ replaces the traditional
community nursing ‘Care Plan’ and provides
an index of care, similar to the index of a
book. It is an innovative development of an
holistic care planning tool for the community
setting.
The document is designed to designate an
identifying number to each concern and track
the page number and date on which the
concern is reviewed.
The concern reviews are conducted at
predetermined intervals with the client, family
and carer using the SOAP documentation
format (subjective, objective, assessment and
plan).
A SOAP includes the client’s thoughts,
feelings and ideas regarding each aspect of
their care along with measurable information,
assessment and continuing plan of care. This
enables clients to be in control of their health
care decisions.
What does the literature say?
Vic Health endorses the Registered Nurses
Association of Ontario (RNAO) Best Practice
Guideline for Client Centred Care. It does not provide
a tool for the documentation of care plans stating
‘documentation tools will need to be adapted to reflect
the client population and the care setting (RNAO,
2006).’
There is evidence within the literature which
demonstrates the value in effective care planning,
however, the process of documenting and
communicating the plan lacks specificity, particularly in
relation to the community setting (Keenen et al, 2008).
This is supported by a number of papers evidencing
the effects of inadequately recorded care planning on
clinical outcomes (Griffiths & Hutchings 1999, Yocum
2002, From et al, 2003).
Outcomes
• Potential for validation as a tool for the
documentation of the plan of care.
• An opportunity for multi-service/disciplinary care
planning with scope to be used as a discharge
planning tool within acute settings.
• Team members have increased their knowledge
base in the areas of practice development,
documentation, research, person-centred care
and Principles of Primary Health Care.
• Developed team members ability for critical and
reflective practice, resulting in a number of other
safety and quality projects being initiated
Works Cited
From G, Pederson M, Hansen J, et al 2003, Evaluating two different methods of documenting care plans in medical records. Clinical
Governance: An International Journal, vol.8. issue. 2, pp. 138–50
Keenan GM, Yakel E, Tschannen D, Mandeville M . (2008). Documentation and the Nurse Care Planning Process. In: Hughes RG
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockwell: Healthcare Research and Quality.
Registered Nurses Association of Ontario (RNAO), 2006, Nursing Best Practice Guideline for Client Centred Care, viewed at
www.health.vic.gov.au/.../02PersonCentredPractice/.../Client%20Centred
Yocum R, 2002, Documenting for quality patient care, Nursing, vol 32, issue 8, pp 58–63.