Assessment and documentation cannot be separated from good resident care. The use of technology, the demand for quality documentation, and the complexities of caring for the older person are some of the many challenges nurses face in long-term care. Nurses must continue to strengthen and enhance their nursing skills relative to assessment and care planning practices to ensure quality resident centred care.

  • Introduction and Overview
  • Conducting a Comprehensive Assessment
  • Critical Thinking and Decision-Making
  • Fundamental Care Planning
  • Bring Care Plans to Life
  • Assessment and Care Planning – an essential responsibility for nurses working in LTC and realities that can complicate this process
  • A review of the nursing process and practice expectations
  • The art and science of assessment
  • Signs of normal aging versus disease and illness
  • The Six Thinking Caps to enhance diagnostic reasoning – physical, functional, high risk areas, mental, psycho-social, nursing wisdom/experience
  • Assess before acting
  • Take action based on assessment outcomes (clinical decision making flowchart)
  • The RN & RPN collaborative process and related accountabilities
  • Components of the care plan (focus, goals, interventions, evaluations)
  • The relationship between the RAI Process and the Nursing Process
  • Communication and documentation that supports an individualized approach to resident care

Learning Outcomes:

  • Realize the importance and benefit of completing an effective nursing assessment
  • Recognize the components within each of the six assessment domains (physical, functional, high-risk areas, mental, psychosocial, and using nursing wisdom – experience, knowledge, and judgement.
  • Demonstrate confidence and skill in your assessment abilities
  • Understand how critical thinking & clinical reasoning guide the nurse when completing an assessment
  • Determine resident-centred care plans
  • Document effectively using best practices, standards and guidelines

This workshop provides hands-on skill development using case studies that allow participants to develop effective, individualized resident care plans. An audience response system will be integrated into the workshop, to engage learners and monitor knowledge gain.

All participants will receive a certificate of attendance.