Client-Centered Care Plans

Reading clients’ medical records can be like reading a foreign language! Doctor's notes, therapist reports, labs, and other test results are all necessary parts of the client record—but none of it tells you anything YOU need to know about providing client-centered care for your client.

That's where the care plan comes in. The registered nurse pulls together all the information from the doctors, therapists, test results, history, and current assessment. Together with client and/or family input, the nurse creates a care plan with specific instructions (in a common language that everyone can understand) for caring for your client!

Care plans are client-centered communication tools used to inform the healthcare team what the client needs and how and why it should be done.

A Good Care Plan:

Is individualized for each client.
Looks at the client as a whole human being—not just as a disease or condition.
Is used daily to direct client care.
Involves all available resources and team members.
Gets updated whenever there is a change in the client’s health status.

What’s Your Responsibility?

Observe your client carefully and report all observations to your supervisor. You spend so much time with your clients that you may be the first (or only) person that knows when your client’s abilities change. This is critical information because it leads to a change in the care plan.
Know the goals. Every care plan includes client goals. Effective goals help direct client care and give a sense of accomplishment to the client and the healthcare team. When you know your client’s goals, you can keep your client on track to accomplishing those goals.
Check the care plan regularly. Review each client’s care plan before each shift and discuss any questions you might have with your supervisor.
Your client’s rights. The care plan should be written in collaboration with the client, but clients still have the right to refuse any part of their care. Don’t force a client to do something just because it’s written on the plan of care. Record what your client has to say and let your supervisor know specifically which care was refused.
Attend care plan meetings. Your presence at regular care plan meetings is valuable. You have input and insight that no one else on the team has regarding the client’s preferences, abilities, emotional state, and progress toward goals.