Individual Support Plan Template
v3.3
Purpose. Case managers, support coordinators and recovery workers use this template to record, with the person, the goals, supports, routines, risks and review arrangements that guide every shift.
1.Purpose of the plan
The plan tells every worker what matters to the person, how the person wants to be supported and what to do when things change. It is written in the person's words wherever possible and belongs to the person. A copy must be offered to the person in the format they prefer.
2.Writing goals
Record two to four goals in the person's own words, and for each goal state what Willow will do, what the person will do and how progress will be measured. Goals for NDIS participants must link to the goals in the NDIS plan. Goals for Support at Home clients must reflect the care plan from the aged care assessment.
3.Daily support and routines
Describe the tasks for each service type, the order the person prefers, the equipment used and the number of workers required. Include how the person communicates, how they make decisions and what a good day looks like.
4.Health, risk and safety
Record diagnoses, medications and who manages them, allergies, falls risk, swallowing or dietary needs, and the transfer method from the manual handling assessment. Record any behaviour support plan, any authorised restrictive practice and the strategies workers must use. Record what to do in an emergency and who to call.
5.People and services
List family, carers, the nominee or decision maker, the GP and other services involved, and what information the person has agreed to share with each. Note any person the client does not want involved.
6.Review
The plan must be reviewed at least every twelve months, after any hospital admission, incident or significant change, and whenever the person asks. Record the review date in the Client Register and the reason for each review in the progress notes.