Rehab assessments and care plans

[suzytil 0]

I"m struggling with my rehab assessments and care plans. We have such a quick turn over that it's hard to get them done timely. I'm looking for a shorter assessment and care plan process. Any ideas???!!

[yunakitty 2]

Yes, if anyone has any input, I'd also love to know.

[Pennie 26]

hey email Big Chris & see if he has any suggestions. he is great at CP writting but not sure if he does this type or not. bigchris1974@hotmail.com -- if you get any good ones or advise please come back here & share them with others OK

[Mel 0]

Most of my rehab residents have this as their "problem:"

 

[name] has been admitted for short term therapy and prefers self directed leisure activities and rest in their room until they are ready to return home.

 

and the goal is:

name] will express contnetment with their personal choices of leisure while they are here.

[dlancaster 0]

I"m struggling with my rehab assessments and care plans. We have such a quick turn over that it's hard to get them done timely. I'm looking for a shorter assessment and care plan process. Any ideas???!!

 

[Dear Suzytil,

Hi. I've workied in a short-term skilled setting for about 8.5 years. Since the terms "rehab" and "short-term Skilled nursing" level of care are often mistakenly used interchangeably, I will ask you if your residents are Skilled Medicare or not. *If they are and you are documenting using medical computer software, you can ask your IT people if the the other diciplines are using a generic, "interim care plan?" This would remain in effect for the first 20 days. If the others diciplines are and you would like to do the same, ask IT if they could create a section for you. You could submit to them a handwritten pattern for them to work off of. I have seen some that are simply a quick series of check-offs - you save you info. - and then you are done. If your residents are staying longer than 14 days, you could aways update/add to the interim care plan in your notes as res. needs may change during the respective MDS observation periods. Just make sure that your care plan is accessible to the other diciplines if they somehow factor in to the activities care plan. An exception to a short interim care plan would be if you have a resident that presents at admission with some type of unique problem or challenge that cannot be addressed in a generic interim plan; in which case in order to satisfy the state, you will still want to create an standard detailed, individualized care plan at admission anyway. Chances are you would only have to do a more detailed care plan, following assessment, occasionally. The government usually follows many "unwritten rules," like that one. I hope that helped.]

Edited November 19, 2009 by dlancaster

[nancyw 0]

this one works well for me

 

concern/problem:name of resident/is at risk to decline in activity participation of choice d/t dx of ????? and prefers in room act.

 

goal/ resident name / will not show signs of declining activity participation 3xs weekly.

 

interventions/ visit resident 3xs weekly and document on indep.log

encourage res. to voice any wants or needs from activity dept. during visits

contiune to invite res. to activities of interest

[Jen 0]

My usual Care Plan for "Rehab To Home" residents, which I personalize, often looks something like this-

Problem/Strength: George is new to facility; anticipates a short facility stay; prefers to engage in self-directed leisure pursuits of _____. He voices enjoyment of social visits from staff et. family et. socializes easily with others.

Goal: George will actively engage in chosen self-directed activity of watching sports on TV et. reading (prefers suspense novels et. needs large print d/t vision deficits) daily in his room.

Approaches:1. Observe for needed reading materials et. provide large print suspense novels from facility library. 2. Periodically invite resident to activities of stated interests, targeting church services et. History Club, while respecting his choice to avoid group activities. 3. Provide brief social visits which may include some of his favorite subjects-talking to George about his family et. past service in WWII.

I have to use the same form I use for all the other admissions because of our P&P, but I approach it in adiiferent way. I ask them what they like to do at home, what interest are they particularly passionate about, what they really don't like, etc. I do they state to them that (this is if they are social people et. don't have a history of being a "loner") that we encourage residents to engage in group programs that interest them because getting them more active beyond therapy will probably help them to get better faster.

[bigchris 1]

Hey guys,

 

I think that I answered this, but I will give another for ya.

 

On the assesment side, we have a standard assesment that several of the activity directors in my company have created and formalized. Yes, it takes time to gather the info for the residents, but the form is easy and only 2 pages long. It has preferences, history, allergies, etc that relate to the resident and once you get into the groove, the actual process gets easier.

 

 

On the careplan, it depends on a few things....but I can give you a sample "I" care plan for our younger, more tech saavy resident...

 

" I enjoy independent activities such as surfing the internet and e mail with family and friends, instead of structured facility activities. Please make sure that I have access to the computer room."

 

 

Since most of our rehab/short stays are in the "boomer" generation, it is not feasible to expect them to enjoy the same activities as the Long Term Residents.

 

It is important to focus on providing unique activities as well......

 

 

 

Hope this helps...

 

Chris