Care Conference Format

Care plan meetings are usually scheduled by the MDS Coordinator. In most facilities she is also the person responsible for writing and maintaining the nursing care plans, and is usually the person responsible for leading the care plan meeting:

• Bring to the meeting the resident’s chart, care plan, nursing assistant care form, and all pertinent documents.
• If family and/or resident is present, introduce yourself and all the IDT members, and ask if there are any concerns, questions, or complaints they wish to discuss first
• Review what has happened with the resident since the last assessment
• Review recent changes in medications and physician’s orders
• Review the nursing care plan, reading each problem statement and discussing with the team, family, and resident as necessary
• Ask each IDT member to review her department’s care plan.
• Discuss with the care plan team if additions or changes need to be made
• Make sure issues related to Falls, Restraints, Skin breakdown, Psychotropic medications, and Weight loss are discussed and that effective interventions are implemented and documented
• Review the resident’s Quality Indicator reports, and address any item that is flagged. Especially focus on Late-loss ADLs.
• Compare the care plan to the MDS 3.0 and Nursing Assistant care form to make sure it all matches. Resolve any conflicting information
• If changes to the care plan need to be made, cross through the old entries with a yellow marker, date, and initial. Date and initial new entries
• Care plans do not need to be completely rewritten with each assessment. They can be edited each time. A rational policy is to reprint the care plan once per year or when a great number of changes have been made. Surveyors like to see a care plan that has been worked on and used
• Take notes of the meeting on Interdisciplinary Team Care Conference form, and when discussion of the resident’s Care Plan is finished, pass the form around the table for signatures
• If there are issues that need to be addressed by other staff, make copies of the Interdisciplinary Team Care Conference form, otherwise, file it in the resident’s chart
• Keep the IDT members focused and from going off on tangents by leading them gently but firmly back to the matter at hand. If a member has a pattern of wasting time in the meeting, schedule a private conference to discuss the problem
• Address family satisfaction issues immediately, assure family members that information will be given to the charge nurse and/or Director of Nursing, and make sure issues are followed up on as soon as possible.
• Ask if anyone present can think of anything else that could help the resident. Promote an atmosphere of loving and caring.

More information about care plan conferences and writing care plans can be found in the book Complete Care Plans for Long Term Care