The individual care plan provides insight into the limitations and handicaps observed by the careworkers and experienced by the patient.

The care plan is drawn up in immediate consultation with the patient / carer, with a focus on the objectives the patient / carer wants to achieve him/herself. On this basis, appointments can be made concerning the interventions.

A care plan is not an aim in itself but a means to:

• endorse individual care;

• clarify the responsibilities and their consequences in and for a care relation to both the patient / carer and careworker;

• be able to establish priorities;

• facilitate the interaction with colleagues and other careworkers;

• coordinate the care;

• evaluate the care;

• endorse continuity;

• facilitate reporting.

 

To be able to draw up an individual care plan the problems of the patient / carer are outlined first. Possible causes of the problems perceived or observed are worked out together.

When careworker(s) and patient / carer are united on the limitations / care needs, agreements are made about the interventions which should be performed in order to minimize the effects of the limitations.

In addition, the objective of care is determined and also who performs which intervention, how the care is evaluated and, when necessary, altered.

In order to facilitate the drawing up of an individual care plan a number of common problems has been converted into a Standard care plan (see chapter Standard care plan). The Standard care plan has been developed on the basis of talks