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Guidelines for Completing the Service Plan/Plan of Care
This Form Can Only Be Completed By a Registered Nurse
Name: Enter the name of the participant.
ID #: Enter the identification number used to identify the participant.
RN Completing Plan: Enter the name of the RN who is developing the Service Plan/Plan of Care.
Problem(s): Enter the problem identified during the assessment that has been placed on the Problem List. These problems should be addressed in the Service Plan/Plan of Care.
Diagnosis: Enter the diagnosis as it relates to the problem identified and/or personal goals.
Medications: Enter all medications currently given that are related to the diagnosis and problem(s) noted. Enter the current dosage and the frequency of the medication used.
Long Term Goal(s): Enter the long term goals that will be addressed for the participant over the long term. They may include, but are not limited to the following:
Prevention of available deterioration;
Maintenance of functioning deterioration;
Opportunities for growth and development or to improve the general health status of the participant;
Activities to reduce isolation or improve the overall quality of life.
Relief for caregivers; or
Restoration/rehabilitation.
Goal No.: Enter the number of the short term goal for the identified Long Term Goal.
Date: Enter the date that the expected outcome goal(s) is developed.
Short Term Goal(s): Enter the measurable objectives/outcomes that can be anticipated if the planned services are carried out and if the participant and his/her caregiver(s) cooperate with the plan. Include measurable criteria to enable staff to identify progress/lack of progress in reaching the expected short term and/or personal goals and desired outcome.
Guidelines for Completing the Service Plan/Plan of Care
Page Two
If it is determined that the goal was not met and a 0 or 3 was entered under Outcome Scores, please comment on page two what revisions need to be made or alternative plans developed to meet this goal.
A back up plan must be entered to address each short term goal in the event that the original approach and intervention cannot be accomplished.
Services, Approaches, Interventions and Provider Type: The information in this section should be specific to the identified needs and characteristics of the individual to enable the staff to achieve the desired outcomes. Enter the specific program activities, services, approaches, interventions and the type of provider, i.e., OT/PT.
Amt./Frequency/Duration: Identify the amount, frequency and duration of the service/staff interventions to achieve the desired outcome.
Discipline Initials: Enter the initials of the staff/service provider responsible for the intervention.
Outcome Scores: This section provides information on the status of the goals identified in the Service Plan/Plan of Care. This section is to be completed whenever the plan is reviewed to monitor progress towards the measurable short term goals. These goals should be reflected on the Quality Assurance document (DHMH 3423) of the Quality Assurance Manual. When updating the Service Plan/Plan of Care, rate the level of achievement according to the Key: Outcome Scores.
Service Plan/Plan of Care Comment Sheet
Name: Reenter the name of the participant.
ID #: Reenter the identification number of the participant.
Long Term Goal(s): Reenter long term goals.
Goal No.: Enter the goal number associated with the short term(s) and/or personal goal.
Comments: Enter the comment(s) that will clearly address the revisions or alternative plans developed to meet this goal.
Service Plan/Plan of Care Comments
Page Three
Signature Record Assessment/Service Plan/Plan of Care Signature Record: Any staff, participant, family member or caregiver that participates in the development of the Service Plan/Plan of Care should sign the signature sheet which indicates participation in the plans development and the approval of the Service Plan/Plan of Care. Additionally, any staff that subsequently reviews the Service Plan/Plan of Care and initials the plan as a reviewer should also complete the signature record at the time of their review.
Note: When developing this plan, Medical Day Care providers must comply with the Medical Day Care, COMAR 10.09.07.05, Medical Day Care Services Waiver, COMAR 10.09.61.03 and Office of Health Care Quality, COMAR 10.12.04.21 regulations.
Rev. 4/15/11
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