guidance for completing this form
The purpose of this template is to record recovery and personalization information in the most recent available plan of care for the specific recipient of mental health care. whenever possible, you should answer all questions. when there is not enough information or clarity, please make a note in the note box. the content of the care plan section is where we hope there will be some difficulty in completing this template and we offer this guide to help. any reference to the person in the document should be understood as the recipient of mental health care.
include the person’s views: Look for evidence that the person had a say in the care plan. the ways in which the objectives are worded could reveal this. For example, “John would like to stop taking his medication” indicates that this is John’s opinion and also suggests an opinion that is not usually apparent to workers.
Reading: How to do a care plan review
co-production: Is there evidence that goals and treatment plans have been co-formulated or show shared ownership of goals and outcomes?
Strengths-Based Assessment: This can be seen in care plans that formulate goals based on an individual’s strengths, abilities, or talents. An example might be “Jane would like to develop her analytical skills by enrolling in a systems analyst training course.”
personalization: Is there evidence of individual choice and control over their care and treatment? Are they based on the person or just what is available? A care plan that focuses solely on medication, side effects, symptoms, or risk should not be seen as personalizing, as it ignores other types of support.
Personal Budgeting: Give people control and choice over purchasing personal social care services to meet their eligible needs. Is there a reference to this or a discussion of the use of personal budgets in the care plan?
recovery-oriented practice: Does the care plan indicate a focus on building recovery, such as facilitating new relationships, assistance with education or return to work, finances, or work? money, personal care or physical well-being? or develop a new sense of purpose?
Person-Centered Goals: Are the goals of care and treatment focused on assessing the person’s needs?
System-Based Goals: In contrast to the above, care and treatment goals focus solely or primarily on system needs, such as treatment adherence.
individual’s views on risk assessment: people are often not asked for their views on risk assessments and many are unaware that they have occurred; when a risk assessment is included, are the person’s views on this evident in the document?
the person’s views on the risk management plan: is there evidence that the person has accepted the risk management plan or has he or she been given an opportunity to discuss it and provide feedback? perspective?
the person’s views on the crisis plan: Is there evidence that the person had a say in the crisis plan, expressed an opinion on it, or indicated agreement or disagreement with the crisis plan? plan? write a note in the notes section to help us understand your answer.
the person’s views in the relapse plan: If there is a relapse prevention plan, have the person’s perspectives been included?
Social Outcomes Orientation: Does the plan show a focus on social outcomes such as relationships and social networks or support, housing, work, or education? if this is partial please make a note in the notes section.
medical outcomes orientation: In general, is the focus on medical outcomes more or less than the focus on personal or social outcomes? please make a note in the notes section to help us understand this.
encouraging self-management: is there evidence that the care plan is encouraging shared responsibility with the person, for example, are there attempts to provide opportunities for the person to create their own plans or objectives?
acknowledging personal relationships: is there evidence of a focus on fostering new relationships or maintaining existing ones?
advance directives: are there plans for when the person cannot make their treatment wishes known? Is it signed and endorsed by the workers?
notes: Use the notes box below the questions to add details. in the larger note box it would be helpful to give an impression of prevalence in the care plan, is it more focused on recovery and personalization in general or is this only a small proportion of the total? include anything else you think is directly relevant to the plan of care that is not otherwise covered.