Service Users Name:

CarePlan

The Care Planshowswhois involvedinaService User’scare,themainfocus;agreedgoalsdevelopedtogether,plannedactionsand whoisresponsibleforeachaction.


Service User

Name:

DateofBirth:// Sex:

oraffixlabelhere

Consent Checklist

Beforedevelopingthisplan,ensureconsenttoshareinformationhasbeenobtained

P

Participants InvolvedinCare

ListknownpersonscurrentlycontributingtotheService User’scare,includingtheindividualandthecarer/advocateandthekeyworker/careplancoordinator/facilitator(e.g.GP,health/communitycareproviders,substitutedecisionmaker,familymembers,volunteersorfriendswhoprovideassistance).Attachsheettospecifyanyadditionalpersons.

Name / Roleorareaofsupport / Contactphone number/s / Otherrelevantcontact details(e.g.agency,email) / Participant inplanning process (yes/no) / Copyofplan provided (yes/no)
Service User
Carer
KeyWorker

Emergency contacts and plan if client does not respond to scheduled visit

Expected Outcome: A risk management approach will be taken prioritising the client’s safety, should there be an emergency or the client does not respond to a scheduled home visit:

1st Contact:……………………………………………………………Relationship: …………………………………………….

2nd Contact: ……………………………………………………………Relationship: ……………………………………………

Specific instructions:

This information collected by:CP Page 1 of3

Name:Position/Agency:

Sign:Date://Contactnumber:

The Person’s Story and Reason for the Plan

CarePlan

Opportunities
(listinorderofpriority) / Agreedgoal(measurable) / Action/stobetakenbywhom / Targetdate
1Pain in the knees – need to investigate cause and treatment options / 1.1Aunty would like to find out causes of her knee pain by the end of March / Action: Arrange a visit to the GP on Thursday at 10am
Who: Aunt: HACC Coordinator or Aboriginal worker will provide information to the GP with Aunty’s consent / Tuesday
1.2Seek advice about treatment and/or pain relief for the knee / Action: Following the GP visit, and if appropriate, arrange an appointment with the physiotherapist at the community health centre
Who: Aunty, Aboriginal worker, HACC Coordinator / Date / time
2 / 2.1
2.2
3 / 3.1
3.2
4 / 4.1
4.2

Plandeveloped:/ /TargetReviewdate://CaseConference: Yes □ No □

Service Userunderstandsandagreestothisplan: Yes □ No □

Signatureifapplicable:Date:// Attachmoresheetsasnecessary.

This information collected by:CP Page 2 of3

Name:Position/Agency:

Sign:Date//Contactnumber:

ReviewofCarePlan

ForusewhentheCarePlanisreviewed.Itshowstheoutcomes/progressofagreedgoalsandplannedactions

OpportunityGoalReference(RefertoCarePlan): / Progress / Sourceof information
Pain in the knees / Aunty has had appointment with GP and understands that she is to participate in gentle exercises; she has started physiotherapy sessions. / Aunty; Aboriginal worker

SupportingDocumentation including Alerts / Key Considerations

Thismayincludesocialprofile,assessments,serviceplans,supportplans,GPplans,advancecareplans,emergencymanagementplans,screeningorriskalerts.Listappropriatedocumentsandsourceorlocation.

This information collected by:CP Page 3 of3

Name:Position/Agency:

Sign:Date://Contactnumber: