Here's a breakdown of who contributes to the plan and their roles:
* RN: The RN is the primary author of the plan of care. They assess the resident's needs, develop goals, and create a plan to achieve those goals.
* Licensed Practical Nurse (LPN): LPNs contribute to the plan by assisting with assessments, providing direct care, and communicating observations to the RN.
* Certified Nursing Assistant (CNA): CNAs provide direct care to residents and communicate any changes in their condition to the RN. They also document resident care activities.
* Therapists (Physical, Occupational, Speech): Therapists assess the resident's needs and develop treatment plans to improve their physical, cognitive, or communication abilities. They contribute to the plan of care by outlining their specific therapies.
* Social Worker: Social workers provide support and guidance to residents and their families. They may contribute to the plan of care by identifying social needs and developing strategies to address them.
* Physician: The physician provides medical orders and diagnoses, which inform the plan of care. They also monitor the resident's overall health and make necessary adjustments to the plan.
* Resident and Family: The resident and their family should be involved in the development of the plan of care and have the opportunity to express their preferences and goals.
The written plan of care is a comprehensive document that outlines the resident's needs, goals, and interventions to achieve those goals. It includes information about:
* Medical history and diagnoses
* Medications and treatments
* Nutritional needs
* Activities of daily living
* Mental and emotional health
* Social and spiritual needs
* Safety considerations
* Rehabilitation and therapy plans
The plan of care is a living document that is reviewed and updated regularly based on the resident's changing needs and progress.