2.1.3 Setting parameters for re-evaluation

The care plan ordinarily includes planned re-evaluation and possible revision, usually at a specific time with a caveat for earlier review if anything unexpected arises or if the course is not working out as expected. The completeness and predictability of the care plan profoundly affect the anticipated timing for review. In a situation where much is not known about the elderly person’s medical issues or when the elderly person does not wish to share information about living situation and desires, the care plan timetable may call for review much earlier than in a more favorable situation.

Care plans also can be rather fluid, as when a newly dependent elder is trying out a series of strategies to provide personal care, or when a challenging medical issue requires ongoing adjustment of treatment to pursue an optimal response. These modifications of details of the care plan need to be documented when they might affect other services and plans. Testing various strategies to learn which works best can also be made part of the care plan.