The importance of assessment in residential care settings cannot be underestimated. It underpins the philosophical approach to person-centred care, an ideology that provides clients with greater control and responsibility regarding their own health and lifestyle.
Every client entering residential care should be given a comprehensive assessment to identify individual needs, preferences, and strengths. The assessment is undertaken by an interdisciplinary team and covers various aspects of their’ lives such as: physical, spiritual, cognitive, social, mental, and emotional.
Client assessments lead to informed decisions that impact on care planning, resources allocation and other services. The assessment process determines the most appropriate and effective way to support clients. Assessment usually starts soon after admission, however it depends of the organization and availability of staff.
A partnership between the interdisciplinary team and client is necessary to conduct a successful assessment.
Clients should be actively involved in their assessment as well as their family/ caregivers and close friends. In many organizations a case manager is assigned to support clients during the assessment process.
Leisure and Health staff are responsible for the Social/Spiritual Care Plan that includes recreation, relaxation, community trips, club affiliation, and other aspects of daily life.
Staff should address the needs of clients and their families in a holistic way. This means that the assessment focuses on the whole person and their entire well-being, including physical, emotional, spiritual, mental, social and environmental.
The Social & Spiritual Profile collects a client’s personal as well as confidential information that the facility may or may not share in the future and therefore should have secure storage.
Gathering information may require more than one meeting with clients.
Some of the customary ways in which the needs are identified include:
Be supportive and non-judgemental to encourage cooperation.
Talking to family and friends may provide useful information about clients. Use discretion and be courteous.
Before developing a care plan, it is important that staff communicate with other health practitioners to gather information outside the scope of their own roles e.g. behaviour management, psychological issues, and special dietary requirements amongst others.
Sometimes it is hard to find words to convey what one sees or hears in an objective way. The list below will assist you when working on documentation at the end of your day.
The documentation process varies from facility to facility but there are usually three important steps to follow.
How to write objective, concise and professional Progress Notes. 4 pages of sample progress notes included.
Learn how to identify the needs of clients entering nursing homes. This article contains detailed instructions on how to conduct a resident assessment which can then be used to create a care plan.
Learn how to respond to the assessment of needs with the following 6 case studies.
Sometimes it can be difficult to motivate residents in nursing homes to attend and participate in scheduled activities. It is important that you identify any barriers - whether perceived or real - that might be preventing residents from getting involved.
Starting a Leisure and Lifestyle Program for residents in nursing homes and long term care requires creative thinking and enthusiasm. Your main point of reference will be the assessment of your clients.
Person-centred care is a philosophical approach in which older people are placed at the centre of their own care by care providers and health services. This diverges from the traditional view of the therapist as an expert and moves towards a non directive approach.
The Social & Cultural Profile Form is an important part of the overall assessment of each individual entering long term care.
Evaluation is the act of assessing a Care Plan to determine its worth. With regular evaulation and quarterly reviews, a care plan is an invaluable tool for residents, staff and family members.