Participating in the Implementation and Monitoring of Client's Care Plan

Unit 01 LESSON 1: Developing development can be your clients’ family

Care Plan members who can provide the medical
A care plan is a detailed form that lists the history that your clients might not be able to
caregiver’s scheduled routine services and give. Healthcare providers/professionals are
tasks based on priority. It summarizes there to give you advice from other medical
clients’ needs, health conditions, and information you need to know.
current treatments caregivers need to
perform within their specified shift. A care Lastly, it is imperative that your clients’
plan should also contain information about doctors must be consulted to gain insight
clients’ medical conditions, medications, into your clients’ past and current
different physical therapy activities, dietary conditions. All these people will help you
or meal plans, healthcare identify the activities and treatment that you
providers/insurance, emotional support need to administer to your clients.
treatment, and emergency contacts.
Through the organization provided by the With this, caregivers can easily know what
care plan, clients' hospitalizations and to do daily, especially in the event of an
emergency room visits may be reduced, emergency. Aside from that, a care plan can
and their medical management may also be help you lead a more healthy life for
improved. yourself. It can provide you with a more
organized work and schedule which can
Caregivers need to have care plans so they also lessen your stress. This can also allow
can provide consistent and quality service to you to contribute effective and
their clients. In making care plans, it is high-standard service for your clients that
important to set goals in a SMARTER may give them full satisfaction with your
approach: performance.

TOPIC 2: Client's Chart

Hospitals, clinics, and other health

establishments usually ask for a patient’s or
clients’ personal information upon entry.
Medical providers do this so they can easily
access or record your personal information
in their system. This document is called a
TOPIC 1: Caregiver's Care Plan clients’ record.
A good care plan must include the inputs of
clients, their family members, healthcare A. Client's Record
providers/professionals, nurses, and their In a hospital, a client's record is usually
personal doctor’s orders. In developing a recorded in a logbook upon arriving. It is
care plan, caregivers must place importance divided into different sections or tabs. The
on their clients’ needs and preferences for following are the several elements that a
they are the recipients of this service. client’s record must have:
Another source of information for care plan

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Participating in the Implementation and Monitoring of Client's Care Plan

B. Client’s Chart Recording all of these details can help you

and your organization keep track of your
A client’s chart is a record of the client's clients essential information, get a clear
basic information written in an individual understanding of their condition, and make
chart per client. . Unlike in the clients’ sound and appropriate medical decisions.
record, in the clients’ chart information like
vital signs must be included. The following
are the several elements that a client's chart TOPIC 3: Risk Management Plan
must have: In one way or another, we are all at risk of
something. Whether we are at home, in
malls, in our workplace, or even while on
vacation, risks are present. But what is a
risk? Risk refers to the chance of people or
properties experiencing negative effects due
to exposure to certain threats and dangers.
When learning about risks, we must keep in
mind that prevention is one of the most
effective ways in managing risks.

Because risks exist to clients, staff, and

organizations in the healthcare setting, it is

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Participating in the Implementation and Monitoring of Client's Care Plan

mandatory for healthcare organizations to the risk-management plan to

establish a qualified risk management plan. promote patient satisfaction.
A risk management plan is a clinical and 3. Purpose,Goals, and Metrics- The
administrative system, process, and report purpose and benefits, including
used to detect, monitor, assess, and prevent goals to reduce liability claims, the
risks. It has a five-step approach, namely: overall cost of the organization’s
risk, and quantifiable data of the
(1) Identifying hazards and those at risk - healthcare risk management plan
knowing which risks should be included and should also be clearly defined.
the people who can be affected 4. Communication plan- Open and
spontaneous dialogue about the
(2) Evaluating and prioritizing risks - information about how to
assessing which risk must be discussed first communicate risk is critical in the
based on priority risk management plan.
5. Contingency plan- The plan is
(3) Deciding on preventive action - required to include emergency
identifying precautionary measures preparedness for disease outbreaks,
long-term power loss, and terror
(4) Taking action - applying the preventive attacks or mass shootings.
action to avoid risks from happening 6. Reporting protocols- The plan
needs to mention the quick and easy
(5) Monitoring and reviewing - regular to use system of documentation for
checking, reporting, and recording need to possible risks and adverse events.
be a part of the plan. 7. Response and Mitigation Plan- It
must include collaborative systems
After familiarizing yourself with these steps, for reported risks and events such
you should also learn the different elements as acute response, follow up,
that a risk management plan should have. reporting, and repeat failure
Here they are: prevention.

Elements of a risk-management plan To clients, the risk management plan can be

1. Education and Training- Employee a safeguard. Older people face a lot of risks,
training requirements must be which include physical abuse, psychological
included in the risk-management abuse, financial abuse, self-abuse, and
plan. It includes the employee’s neglect. Other than these abuses, other
orientation, ongoing, and in-service common risks for seniors are transportation,
training, annual review, and crime, and confidentiality. These risks
competency validation, and should be addressed and included in the
event-specific training. risk management plan to prevent future
2. Patient and family grievances- harm and provide protection for clients.
Procedures for documenting and
responding to patient and family To the organization, the safeguard of their
complaints should be described in assets, market share, accreditation,
reimbursement levels, brand value, and

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Participating in the Implementation and Monitoring of Client's Care Plan

community standing are some of the performing motion exercises are

significance of a risk management plan for encouraged among older adults.
them.
As mentioned in the previous module, aging
A good healthcare risk management plan causes our bones and vertebrae to become
should be frequently updated based on less dense, which thus affects our range of
emerging risks, lessons learned, new data, motion.
and changes in the healthcare system and
practice of medicine. Range of motion refers to the extent of your
movement at each joint in your body. In
order to know the measurement of the
UNIT 01 LESSON 2: Support Activities range of motion, we must first familiarize
ourselves with the types of body
Most older people experience health movements. All of these are important to be
problems including physical, mental, and identified and measured among the elderly
emotional. That is why providing activities so that they may be given the proper
that will make your clients more productive treatment.
is one of the many duties the caregiver has
to fulfill. Types of Body Movements
Learn about the different types of body
movements and know how to perform them.

1. Flexion- The joint contracts and

decreases its degree angle.
2. Extension- The joint contracts and
increases its degree angle.
3. Dorsiflexion- The distal end of the
foot is pulled toward the tibia.
4. Plantarflexion-The distal end of the
Motion exercises, therapeutic exercises, foot pulls away from the tibia.
recreational activities, play therapy, and 5. Abduction- The limbs move away
music and art therapy are some of the from the body’s midline in the frontal
activities that are waiting for you in this plane.
lesson. Let’s go! 6. Adduction- The limbs move forward
the body’s midline in the frontal
plane.
TOPIC 1: Motion Exercises 7. Circumduction- An end of the body
Our bones, joints, and muscles will region moves in a circular motion,
inevitably undergo changes as we age. while the other end stays relatively
Usually, these changes cause movement stationary.
limitations, joint problems, and muscle pain, 8. Rotation- The ball-and-socket joints
which are some of the most common do a spinning motion.
complaints of our elderly clients. This is why 9. Lateral rotation- A body part turns
away from the midline.

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Participating in the Implementation and Monitoring of Client's Care Plan

10. Medial Rotation- A body part from an external force because of

rotates towards the midline. muscular weakness, fatigue, or pain.
11. Supination- The wrist rotates in a Assistance may be applied
lateral motion. manually, mechanically, or by
12. Pronation- The wrist rotates in a gravity, while the clients perform a
medial motion. voluntary muscle contraction to their
13. Eversion- The ankle turns to make extent.
the sole of the foot face away from ● Active Range of Motion Exercises -
the midline. It is performed independently by
14. Inversion- The ankle turns to make clients who can voluntarily contract,
the sole of the foot face toward the control, and coordinate a movement.
midline.
15. Protraction- The mandible TOPIC 2: Therapeutic Exercises
(jawbone) Pushes forward. Therapeutic exercises are performed to
16. Retraction- The mandible (jawbone) correct particular body problems and
pulls back. improve body function. They are physical
17. Depression- The mandible activities that focus on restoring and
(jawbone) moves downward. sustaining a person’s strength, endurance,
18. Elevation- The mandible (jawbone) movements, postures, flexibility, balance,
moves upward. and stability.
19. Opposition- The thumb moves to
touch each fingertip. ● Endurance or Cardiovascular
Exercises Are any activity that
In order to improve their range of motion, increases heart rate, respiration,
older adults are encouraged by healthcare oxygen, and blood flow that aims at
team members to participate in physical engaging large muscle groups over
activities such as the range of motion a longer period. These exercises
exercises. This type of exercise is done to can be helpful for the
improve the flexibility and mobility of joints. Heart,Sleep,Mood, Weight
It is important that joints and muscles are regulation and metabolism.
moved every day to keep them flexible and Examples of Endurance or
improve their balance and strength. Cardiovascular exercises
1. Ball beats (Drum alive)
There are three types of motion 2. Ball exercise
exercises. 3. Frisbees

● Passive Range of Motion Exercises - ● Resistance exercise

It is performed with the help of the Are activities that increase strength, Tone,
caregiver for clients who have and mass by contracting muscles against
special needs because they are an external resistance. These exercises
unable to move their body parts. help build muscle strength and tone, slow
● Active-assisted Range of Motion down or reverse the aging process, build
Exercises - It is performed when the bones, raise metabolic rates.
clients require help with movement

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Participating in the Implementation and Monitoring of Client's Care Plan

Examples of Resistance Exercise TOPIC 3: Recreational Activities

1. Chair stands It is normal for our clients to experience
2. Straight Leg Raises boredom sometimes. If you are thinking
3. Wall Push-ups about how you can give your clients various
activities that they can enjoy for their leisure
● Flexibility Exercises time, you might want them to engage in
Are activities that improve the ability of a recreational activities.
joint to maintain the movement necessary
for carrying out daily tasks and physical Recreation can satisfy a variety of needs for
activity. These exercises may help the body people, especially seniors. Recreational
experience fewer injuries, lesser pain, activities are outdoor activities done for the
improved posture, Have a positive state of purpose of exercise, pleasure, relaxation,
mind, greater strength and improved and practice. These activities play an
physical performance. important role in enhancing their quality of
life. The benefits of recreation for our clients
Examples of Flexibility Exercises are improved health and fitness, additional
1. Shoulder stretch opportunities for socializing, enhanced
2. Chest stretch skills, and new learnings. Listed below are
3. Back stretch the different recreational activities you can
encourage your clients to do during their
● Balance and coordination free time:
exercises
Are activities that can improve your body ● Walking
stability and ability to perform better As basic as it may sound, walking is actually
movement for the different parts of the body one of the most important exercises.
at the same time. These exercises will help Every morning or afternoon, you can take
you in reversing the age-related loss of your clients for a 30-minute walk to get
balance,prevent falling, build better posture, some fresh air. Make sure to tell them to
faster recovery from injury, and increase wear comfortable clothes and shoes before
muscular power performance. walking. It may help them exercise their
body every day and improve their emotional
Examples of Balance and coordination well being.
exercises
1.One foot stance ● Gardening
2. Toe Taps Gardening is the best recreational activity
3.Heel to toe walk for clients who love nature.
You can start by getting a patch of land or a
Including these in your clients’ daily routine plot, and plant a seed that is easy to take
tasks can bring improvement in their joints care of. It is a good practice for them
and muscles in the next several weeks. You because it helps reduce their stress and
can also perform these with your clients, lower their chances of developing
and become their exercise buddies! depression.

● Sports

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Participating in the Implementation and Monitoring of Client's Care Plan

If their doctor permits and their bodies can Taking part in these activities can greatly
perform well, sports is a good activity for improve your client’s physical and mental
older people. health.
You can ask your clients what sports they By doing these, your clients can enjoy,
prefer , and suggest activities like learn, relax and can even be productive
swimming, badminton, tennis, or anything during their leisure time. It can be a good
that may interest them. Sports can also be a start for them to discover new hobbies or
good way to meet people and socialize. tasks to perform whenever they want to do
something interesting.
● Yoga
Yoga is a way to relax the body and mind. TOPIC 4: Play Therapy
You can suggest to your client’s family to Play has been used in various disorders like
enroll them in a yoga class. Improving cerebral palsy, autism, cognitive disorders,
physical health as well as mental health are dementia, stroke, head injury, learning
the benefits of yoga. difficulty, depression, anxiety disorder,
ADHD, mental stress, and many more.
● Reading and writing
Make sure to put reading and writing as Play therapy can also be applied to adults
options for recreational activities if your and even older adults to help improve their
clients enjoy books,notebooks, and pens. brain functionality, release endorphins, and
You can give a book which they can relate stimulate creativity. Play therapy is
to and tell them to write a review about it. performed to help people express, learn,
This way, they can sharpen their memory and communicate with the environment. It is
and creativity. also considered a form of counseling or
psychotherapy for people who have
● Socialization psycho-social challenges.
It is important for your clients to discover
social connections with others. You can do These are the examples of play therapy that
this by engaging them in socialization. Let can help seniors increase their body
them meet new people that have the same function, abilities, and socialization:
interest as them where they can share their
thoughts and build relationships. These are ● Toy and Object Play techniques
the ways you can make them engage in This therapy uses toys like balls. One
socialization: example is to involve your clients in a group
1. Do volunteer works play where they take turns in throwing a ball
2. Participate in social events around or you can play with them. Aside
3. Visit senior centers and facilities from exercising the arms, your clients can
4. Build positive relationships with their also improve their social skills by playing
family members and communicating with other people.
These activities can help them improve their
feelings of isolation and loneliness. ● Storytelling Techniques
This therapy involves you and your clients.
In this techniques, there is someone who
will tell a fictional story and by the end of it,

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Participating in the Implementation and Monitoring of Client's Care Plan

the other one will tell the lesson of the story. being. Improvement of moods, relieving
Communication and speech skills are stress and anxiety, enhancing emotional
enhanced with this technique. expression are some of the benefits this
therapy can give.
● Brain Games Techniques
This therapy uses brain games like One example of this is INDAK or “Rhythm”
crosswords puzzles,Sudoku, coloring in Filipino, which is a home based program
books, and scrabble in this technique. It is for older people with mild cognitive
beneficial to clients and trains the mind to impairment offered by the institute for
think and make different strategies. Dementia Care Asia (IDCA). INDAK stands
for improving Neurocognition through Dance
These different play therapies will surely be and Kinesthetics.
helpful for your clients to improve body and
brain functions. It can also provide them This program, which they also called
some entertainment in their free time! “Dance of the brain,” consists of 8
structured dance modules designed by a
TOPIC 5: Music & Art Therapy multidisciplinary team. They combine music,
Managing, expressing, and communicating dance recall, and physical exercises that
feelings can be a tough thing to do for some aim to improve memory, lessen stress and
of our clients, which is why creative depression, and maintain or improve their
therapies are encouraged among those who current abilities.
have these challenges. This type of therapy
is particularly helpful for clients who are 2. Art Therapy
experiencing intense and complex The use of drawing,painting,sculpture, and
emotions. collage are some of the methods in art
therapy. This therapy focuses on inner
Music and art therapy is one way of experience, feelings, thoughts, perceptions,
addressing traumatic or uncomfortable and creative processes. Some of the
situations. It can help nurture personal benefits this therapy can deliver are
growth and healing. Clients do not need to managing stress well, learning coping skills,
be good or have a background in music or boosting self esteem, and uncovering
art to perform this therapy. They can try it by creativity.
just expressing what they truly feel. Through
this, our clients will be able to improve the These are the following examples of art
way they manage emotions. Aside from Therapy:
that, music and art therapy can reduce
symptoms of psychological disorders,
For emotions: For Relaxation:
reduce stress, and generate creative ideas. ● Make a ● Make
journal drawings in
1. Music Therapy ● Draw or the sand
It incorporates techniques like making paint ● Paint with
music,writing songs, and reflecting on emotions music
music. This therapy uses connection to ● Make a ● Do finger
stress painting
facilitate positive changes in emotional well

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Participating in the Implementation and Monitoring of Client's Care Plan

painting ● Color in
● Use line different
artworks designs
● Paint ● Make
mountains mandala art
or valleys

For Trauma and For Self:

Sadness: ● Make a
● Create a drawing of
diorama of different
experience good traits
● Paint a loss ● Sculpt the
loved ones ideal self
● Make a ● Wok on a
collage visual
● Draw scary photography
things ● Make a box
● Make art of values
from a
destroyable
thing E.g
sand, paper,
etc.
By encouraging your clients to create art,
talk about it, and express it, you are already
helping them cope with their emotional
conflicts.

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Participating in the Implementation and Monitoring of Client's Care Plan

can help you record information

UNIT 02 LESSON 1: Preparing automatically, be more organized, and can
easily be monitored.
Complete Daily Reports and
Records In this lesson, we will guide you through the
principles and guidelines of quality
Introduction documentation and recording, as well as the
One of the good practices in every health different types of documentation. If you are
care worker is keeping records and reports all set, let’s get started!
of your performance. Daily records and
reports are where important things should TOPIC 1: Principles and Guidelines for
be recorded because they will be used for Quality Documentation and Recording
future purposes. All information that is Documentation refers to the process of
relevant to clients’ conditions should always recording any written or electronically
be accurately recorded and reported to help generated information about clients. It
you deliver quality service to your clients, includes the status, care, service, and other
and to help your clients achieve the best things to remember for your duty.
possible treatment.
On the other hand, recording is the process
The purposes of complete daily records and of listing down any information for the
reports include decision-making, legal purpose of preserving it. Through
accountability, assessment, quality documentation and recording, caregivers
assurance, and planning. For these can communicate their observations,
purposes, what are the things you should decisions, and actions for clients. Learning
include in your records and reports? the different principles and guidelines for
quality documentation and recording is a
vital part of your job.

Nowadays, it is much easier to keep records

and reports. The use of technology like
computers is practiced mostly by
professionals including health workers. It

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Participating in the Implementation and Monitoring of Client's Care Plan

REMEMBER: Documentation and recording mentioned above, but don’t worry because
SHOULD always remain confidential. It we got your back in this lesson!
should follow the rules under RA 11073 or
Data Privacy Act and RA 9995 or Anti-Photo TOPIC 1: Defining Endorsement Process
and Video Voyeurism Act of 2009. Keep in Good communication between healthcare
mind that one of the many duties of a workers and clients is a good practice of
caregiver is to protect your client’s privacy. safety culture for both of them.

TOPIC 2: Types of Documentation One way of practicing this is to perform an

A document refers to a written or printed Endorsement Process. Let us watch this
piece of official record that contains video to know how this works:
important information. In the previous topic,
we defined documentation as a process of The endorsement process is a clinical
recording any written or electronically handover procedure that is done by
generated information about your clients. healthcare workers to serve as shifting
Now we will discuss the different types of reports for incoming and outgoing nurses or
documentation that we will encounter as caregivers.
caregivers. The process is done every change of shift of
the nurse or caregiver who is assigned to
Here are the two types of documentation: the specific clients.
It is the transfer of accountability from one
● Assessment Report healthcare worker to another.
A type of documentation that contains facts
and data recorded from an evaluation for This process must be done using ISBAR
the purpose of changing or improving communication.
clients’ treatment.
● Care Plan ● I for Introduction-present
A detailed form that lists the caregiver’s information like name and time shift
scheduled routine services and tasks based first.
on priority. It summarizes clients’ needs, ● S for Situation-inform the client and
health conditions, and current treatments the caregiver in charge of what is
caregivers need to perform within their happening at the moment.
specified shift. ● B for Background- raise all issues
that led up to this situation.
● A for assessment- include the
LESSON 2: Conducting Endorsement clinical diagnosis.
Process ● R for Recommendation-declare the
Introduction details on the actions to be taken.
In the healthcare industry, the given
scenario presents the need for an One of the most important components of
endorsement process. Endorsement is the the endorsement process is the handover.
act of approving something for another The handover must happen at each client’s
person with a specific purpose. You might house.It involves the caregiver who is
stumble upon the same situation we initially in-charge of the care of the client,

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Participating in the Implementation and Monitoring of Client's Care Plan

and the caregiver who will take over should be understandable. All information
afterwards. must be written correctly, clearly, legibly,
and in a language that everyone can
In this procedure, clinical alerts that can understand.
happen must be identified.Such alerts
include allergies,infection,side effects from This process is essential for clients’ safety
medicines, etc.After this, the outgoing because it ensures the communication and
caregiver should declare the knowledge between caregivers and patients
focus,goals,intervention,evaluation and regarding the healthcare plan. It can also
endorsement for the client to the incoming serve as a medium to increase the
caregiver. awareness, knowledge, and satisfaction
related to treatment. Safety is secured
The clients and guardians are encouraged when a caregiver is careful in every process
to participate in the handover so they can taken. All is well if you will take note of
be aware of the care plan for the next shift. these in your endorsement process.
The caregiver should also perform an
inventory for the medicines, and document TOPIC 2: Interpreting Status of Client
the whole handover procedure. Health and Activities
Subjective data is the information you need
This process is usually done by using a care to interpret the status of your clients’ health
plan if it is home-based and a cardstock and activities. They provide you with
system if it is done in a hospital. A cardstock information for possible physiologic,
system is a medical information system that psychological, and sociological problems.
is used to communicate important They can also give you facts that may
information to clients and nurses. It is a way reveal the clients’ risk for a problem or
to make a quick summary of an individual areas of strength. These data consist of:
client's needs that is updated with every
change of shift. 1. Sensations or symptoms
Feelings like numbness,tightness,tingling or
Below is a sample of a cardstock system: burning are some of the things you must
interpret if ever your clients are
experiencing any of these.
2. Feelings
Your clients’ emotions should also be
prioritized so you’ll know if they are affecting
their health conditions.
3. Perceptions
Know how your clients interpret and
organize their sensory information.
This endorsement process should include 4. Desires
therapeutic communication where clients Ask your clients what they want to do. By
must be guided in expressing their feelings doing this, you might improve not just their
and ideas whether verbally or nonverbally. mental health but their physical health as
Details like abbreviations and symbols well.

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Participating in the Implementation and Monitoring of Client's Care Plan

5. Preferences
Learn how your clients respond in decision
making. You can facilitate improvement by
just knowing what they always prefer.
6. Beliefs,Ideas, Values
You should know your clients’ beliefs,ideas
and values to show respect to them.
7. Personal information
A lot of data can be gathered by just looking
through your clients’ information. It may help
you interpret their health status.

These data are accumulated and collected

through interviews. The information that you
will obtain must be accurate to help you
interpret your clients’ health and activities
according to what their body conditions
need.

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