Nursing care plans in acute mental health nursing

Nursing in acute mental health nursing Robert Tunmore, MA, BSc(Hons), PGDip, RMN, RGN, IPD Cert, Academic Co-ordinator, Principal Lecturer, Institute of Health Studies, University of Plymouth; and Ben Thomas, MSc, BSc(Hons), RMN, RGN, DipN, RNT, CertHE, FRCN. Director of Nursing, Somerset Partnership NHS & Social Care Trust, Principal Lecturer, Institute of Health Studies, University of Plymouth Article 528. Tunmore R and Thomas B (2000) Nursing in acute mental health nursing. Mental Health Practice. 4, 3, 32-37. Care plans play an important part in mental health nurses work, not only as a legal record of care given, but as a therapeutic tool. This article sets out the principles of good record keeping and how nurses can make them more accurate and effective key words and planning patients records These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. Aims and intended learning outcomes This article promotes the care plan as a means of providing more effective care on acute inpatient units. It emphasises the use of such plans within the context of a therapeutic relationship, using the care plan as a therapeutic tool. It highlights professional standards for record keeping and sets out the legislative framework for care planning in mental health nursing. This article aims to promote understanding of the principles of good record keeping, and to develop more effective and accurate records. After reading this article, you should be able to: Identify ways and means of using the care plan as a therapeutic tool. Identify professional standards for record keeping. Understand the importance of the care plan as a legal document. Improve your own skills in writing. Introduction For mental health nurses the importance of the nursing care plan is twofold. First, it can be used as a therapeutic tool, a means of engaging the client, their relatives and others in planning, setting and meeting goals in care. It plays a key part in ensuring continuity of care and communication across and between the different parties involved in providing care to individuals and their families. Second, nurses have a professional responsibility for written and for the care planning process. In addition to being accountable to the client and his or her relatives, the mental health nurse is legally accountable for the care they provide. The nursing care plan may be used as a legal record of an individual s care. Background There is little evidence in the psychiatric nursing literature that demonstrates the impact of on client care and clinical outcome. Clinical effectiveness is not yet established (Thomas 1996). The Sainsbury Centre (1998) surveyed of 113 acute inpatient units. Half of the problems identified in the care plans related to psychiatric illness, signs and symptoms, 20 per cent to risk of danger to self or to others, 10 per cent to physical health problems and 10 per cent to other issues. Interventions related to two main areas of care; psychiatric treatments and medication and milieu-related interventions, including, for example, spending time with the patient. Generally, lacked any evidence base for interventions. Few linked the intervention to a particular outcome and evaluations were seldom completed. Thomas (1999) reports on an audit of and finds little connectivity between assessments, and progress notes, a lack of prioritisation of needs, and little evidence of evaluation, outcome measurement and discharge planning. Neilson et al (1996) address the use of the care plan in relation to risk assessment and management and report that often nurses reactions to service users do not follow the written nursing care plan, and that the care outlined in the care plan was not a good reflection of the actual nursing care provided to service users. 32 MENTAL HEALTH PRACTICE NOVEMBER 2000 VOL 4 NO 3

Reynolds et al (1992) suggest that mental health practitioners generally receive little training in how to write and read a record, given the amount of time they tend to spend doing both. The literature suggests that nurses need assistance in developing care planning and record-keeping skills, but few research studies indicate methods to assist the nurse in improving these skills (Reynolds 1982). Some have developed audit tools to try and measure the quality of care planning (Teggart 1993) or by reviewing care planning procedures (Perkins and Fisher 1996). Shea (1986) reports from research focusing on nurses attitudes and beliefs about and suggests that only 40-60 per cent of clients have written that are used. Neilson et al (1996) surveyed a random sample of from acute psychiatric inpatient units addressing initial assessment; formulation of a care plan; co-ordination and implementation of care; evaluation and discharge planning. Overall, the quality of nursing was poor. De la Cuesta (1983) found nurses gave many reasons for their inability to care plan appropriately, including difficulties in articulating written problem statements and with analysis of data. Many nurses saw little relationship between the written plan and the actual care of the service user. They reported insufficient time to record the. At worst, were seen as unnecessary administration and bureaucracy of little clinical value. However, Yassin and Watkins (1993) found that education helped to foster more positive views towards care planning. Siegal and Fischer (1981) conducted the most comprehensive study of psychiatric records to date. This involved a national survey of over 4,000 multidisciplinary mental health professionals attitudes toward psychiatric records. The following are the main results of the survey: 60.5 per cent believed that there was some relationship between good records and good care, with an additional 26 per cent holding that there was a good relationship. The most pervasive problems were illegible handwriting, too much information, no problems identified at all, missing information and disorganisation of records. The clinical parts of the records were most frequently written and read. Most records had a structured format, progress notes, however, were generally unstructured. The records were used in different ways; psychiatrists, psychologists and social workers consulted records to make decisions, other staff consulted records to get instructions. Records for long-term service users were sparse compared with other groups of service users perhaps an indicator of less active treatment. Psychiatrists made the greatest number of entries, psychologists the least. Nurses and psychiatrists emerged as the most frequent record users. About one third of treatment plans were missing from the sampled records. TIME OUT 1 Take two large sheets of paper and write the headings What is going well on one piece and What is not going so well on the other. With colleagues, reflect on the research findings and the recommendations of the mental health inquiries outlined in this article in relation to your ward or unit and brainstorm points to go under each of the two headings. Try to organise the points or issues you identify into common themes. Service user involvement in care planning An absolute minimum standard of user involvement is the signing of the care plan by the service user. This may imply his or her agreement with its content, or merely that he or she has had access to the care plan. However, if the client has not signed the care plan the reason should be recorded. Sheehan (1991) investigates the use of the care plan and reports a lack of negotiating with service users about the care they are given. Fanning et al (1972) assessed the attitudes of service users and staff in a mental health centre to service users participation in planning their own care. There was agreement between service users and staff that care and treatment should be planned collaboratively from the time of admission. The main problem with joint planning lay in its implementation. Simonton et al (1977) conducted a study on the effects of giving service users in a small psychiatric unit their complete medical and nursing notes to read on a daily basis. Medical and nursing staff and service users found this to be an effective way of actively involving users in treatment and provided opportunities for user education. Other advantages included a lower rate of inaccuracies in the records and greater care in documentation by staff. Dirkensen Yoder (1990) involved a small sample of service users in the evaluation of nursing actions and interventions documented in, asking them to rate them according to helpfulness and frequency of intervention. Overall, service users valued actions that promoted independence, helped them learn new skills and increased knowledge relating to their medication. Being knowledgeable, competent, and friendly were identified as important characteristics of the nurse associated with the implementation of nursing actions. The development and evaluation of a shared care record held by service users with severe mental illness in long-term care was the focus of a study by Essex et al (1990). Service users found the shared care records very acceptable and were enthusiastic about their use. They valued being consulted about what was recorded and found the record of their treatment and progress useful. They felt more informed and better able to make decisions. Shared-care records were acceptable to service users with severe mental NOVEMBER 2000 VOL 4 NO 3 MENTAL HEALTH PRACTICE 33

Box 1 User and carer involvement User and carer involvement can be promoted through: Developing the care plan in conjunction with users and carers. Shared open communication between users and carers and professionals in needs assessment. Providing summaries of assessments to users and carers in the form of a written care plan. Involving key workers, advocates or other people during the care planning assessment interviews. illnesses. They increased the service users autonomy, and improved communication and effectiveness of shared care. Attitudes, perceptions and anxieties among doctors, nurses and managers were the main obstacles to this approach. TIME OUT 2 Conduct an audit of the care plans on your unit to identify any evidence of user and carer involvement in care planning. Consider ways of improving user and carer involvement in the care planning process. What would you expect to see as a result of this improvement write down how would you measure or evaluate changes? Check other details, for example, that the record is signed, the information complete and accurate and that the care plan complies with the standards for good record keeping, set out in Box 2. Mental health inquiries In addition to research findings, reports and recommendations of mental health inquiries provide another source of evidence as a basis for practice. The Zito Trust offers a review of 58 mental health inquiries between 1969-1996. At least 21 of these inquiries identify assessment,, documentation and record keeping as areas requiring attention. Specific recommendations relate to improved communication, interagency referral and working, and a systematic approach to user information (Sheppard 1996). Recommendations associated with, record keeping and documentation, include: The need for a single record for each service user Problems of communication of information between different professionals increase when each professional group keeps its own separate clinical record. Also, a single record system would allow information to cross organisational boundaries, for instance, between community care and in-service patient unit, primary and secondary care, primary care team and mental health or specialist service. Access to and sharing of information would be improved. Organisation of records Many inquiries comment on the poor organisation of records and the problems this causes with finding relevant information when it is needed. Some recommendations suggest chronological systems reflecting the service user s experience of health and social care to date, with a separate section for specific tests and investigations. Content of records Often the most relevant or most important information about care was simply not recorded. Essential information includes any incidence of violence or aggressive behaviour; prescribed medication and the actual experience of side-effects; legal status, whether the service user is detained under the Mental Health Act and the period covered; the relevant level of supervision and observation; pass status, whether or not they should be accompanied, if so, by whom; and, importantly, any changes in care need to be clear in the record. Responsibility for records Reports from inquiries often comment on the lack of clarity over who is responsible for what in relation to the records. Each professional may make assumptions about what other professionals would record. This may lead to repetition and/or omission of information. Involvement of service user and family in care planning The general lack of involvement was remarkable, particularly when the carers or families knew of information that could have made a difference. In one instance a professional even discounted the carer s opinion. Assessment and history taking Some inquiries are critical of professionals lack of skill in conducting and recording assessment interviews. Some clients had experienced being assessed by several different professionals, each ignorant of what his or her colleagues had already done. Risk assessment One of the common problems identified by enquiries was the poor state of knowledge of risk assessment and risk factors in relation to the client and his or her care. At times, there was variation across different professional groups as to what constituted a risk assessment. Nurses, doctors, police and social workers do not always share a common understanding of what constitutes a risk. Care plans should specify the type and nature of risks to self, others or of neglect. Audit of documentation Most enquiries recommend regular audit of records to ensure that they reach a minimal desired standard. Need for on-going training The lack of education and training in care planning is highlighted. Regular training helps to maintain standards of documentation and can meet the needs or deficits in care planning skills identified in the audit of records. TIME OUT 3 Read through a recent local mental health inquiry and identify any recommendations associated with care planning, documentation and record keeping. Consider the implications of these in relation to the organisation of care planning on your own unit. You may wish to review relevant trust policies and procedures. Develop an action plan for improving care planning practice. UKCC guidelines The UKCC identifies record keeping as a fundamental part of nursing and midwifery practice. The Guidelines for Records and Record Keeping (UKCC 1998) promote good record keeping as a mark of the skilled and safe practitioner. Accurate records protect the welfare of service users by promoting: High standards of clinical care. 34 MENTAL HEALTH PRACTICE NOVEMBER 2000 VOL 4 NO 3

Continuity of care. Better communication and dissemination of information between members of the interprofessional healthcare team. An accurate account of the treatment and care planning and delivery. The ability to detect problems, such as changes in the service user s condition, at an early stage. The care plan as a legal document The UKCC guidelines state that the registered nurse has both a professional and a legal duty of care. This calls for a standard of record that includes: a full account of the assessment and care planned and provided; relevant information about the condition of the service user at any given time and the measures taken to respond to their needs; evidence that the duty of care has been understood and honoured, that all reasonable steps to care for the service user have been taken and that any actions or omissions have not compromised their safety; a record of any arrangements made for the continuing care of a service user. Most NHS trusts will have agreed local standards relating to documentation and record keeping. These may cover the minimum or expected frequency of entries into, e.g. an entry every 12 hours covering day and night, or the length of time between admission and documentation of a care plan. A sound working knowledge of local policy is central to professional decision-making and practice. Nurses are duty bound to work within the standards set out in the Professional Code of Conduct (UKCC 1992) and the policies and procedures of their employing trust. TIME OUT 4 Read through your trust s policies on care planning, documentation and record keeping. Write down basic requirements including: Who is responsible for the care plan. The acceptable minimum time from admission that a service user should have a preliminary care plan. Frequency of entries into the care plan. Key people to be involved in the care plan. Appropriate assessment tools and other documentation associated with the care plan. Any other local standards governing the care planning process. Consider these requirements in relation to the Profession s Guidelines for Records and Record Keeping (UKCC 1998) (available from United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 23 Portland Place, London W1N 4JT. Common problems with care plan statements The UKCC s Standards for Records and Record Keeping (UKCC 1993) states that inadequate and ineffective record keeping may lead to: impaired continuity of care; discontinuity of communication between staff; the risk of medication or other treatment being duplicated or omitted; failure to focus attention on early signs of deviation from the norm; failure to place on-record significant observations and conclusions. The Sainsbury Centre (1998) survey reports that many included goal statements, such as, To develop a therapeutic relationship with the patient with no description of how this should be achieved. Very broad statements are generally unhelpful. A more specific and focused client-centred approach is necessary. Box 3 identifies other general and meaningless phrases in common use. All too often, care plan statements, problems and goals are similar for any number of service users on a particular inpatient unit, despite those individuals having quite different experiences and needs. Care plans should be specific to the individual, i.e. individualised. The types of statements in Box 3 may identify what mental health nurses do as a routine part of their work with all service users. Such statements do not individualise a care plan nor provide a plan of service user-centred care. However, they may indicate the broad approach to care that is adopted by nurses on the unit. They could be used to reflect the overarching context of care and, for example, be incorporated into a unit or ward philosophy. Additional problems include the interchangeable use of problem/need statements, goal statements and interventions; the use of terms or statements that are vague and unclear; that focus on the nurse s responsibility rather than the service user s needs or problems and statements that are too prescriptive, unrealistic, verbose and lengthy. The use of abbreviations, jargon, speculative or subjective statements should be avoided. TIME OUT 5 Select a sample of current care plans in use on your unit. Go through them and identify any patterns in the types of statements that are recorded. For example, some, such as those in Box 3, may be common. Discuss with your colleagues the effects of taking such statements out of the care plan and replacing them with more focused, individualised statements with a view to making the care plan more relevant to the service user s specific problems and individual needs. The nursing process The UKCC acknowledges that there is no single approach to record keeping (UKCC 1998). However, most follow a similar format, often associated with the stages of the nursing process a problem-solving approach to the care of the individual. Most will include the following sections: Box 2. Content and style of effective records (UKCC 1998) Records should: be factual, consistent and accurate; be written as soon as possible after an event has occurred, providing current information on the care and condition of the service user; be written clearly and in such a manner that the text cannot be erased; be written in such a manner that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read clearly; be accurately dated, timed and signed, with the signature printed alongside the first entry; not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements; be readable on any photocopies. Records should also: be written, wherever possible, with the involvement of the service user or their carer; be written in terms that the service user can understand; be constructive; identify problems that have arisen and the action taken to rectify them; provide clear evidence of the care planned, the decisions made, the care delivered and the information shared. Box 3. Care plan clichés Assess mental state Maintain a safe environment Establish one to one Orientate to ward environment Develop a therapeutic relationship Give medication as prescribed Monitor signs and symptoms Allow patient to ventilate his/her feelings NOVEMBER 2000 VOL 4 NO 3 MENTAL HEALTH PRACTICE 35

REFERENCES De la Cuesta C (1983) The nursing process: from development to implementation. Journal of Advanced Nursing. 8, 3, 365-371. Dirkensen Yoder S (1990) How are you doing? Service user evaluations of nursing actions. Journal of Psychosocial Nursing. 28, 10, 26-30. Essex B et al (1990) Pilot study of records of shared care for people with mental illness. British Medical Journal. 300, 1442-1446. Fanning VL et al (1972) Service user involvement in planning own care: staff and service user attitudes. Journal of Advanced Nursing. 4, 627-634. Gordon M (1997) Manual of Nursing Diagnoses: 1997-1998. St Louis, Mosby- Year Book Inc. Jenkins R (1990) Towards a system of outcome indicators for mental health care. Journal of Psychiatry. 157, 500-514. Neilson T et al (1996) Does the nursing care plan help in the management of psychiatric risk? Journal of Advanced Nursing. 24, 1201-1206. Newell R (1994) Interviewing Skills for Nurses and Other Health Care Professionals: A structured approach. London, Routledge. Pankratz D and Pankratz L (1973) The nursing care plan: Theory and reality. Supervisor Nurse. April, 51-55. Perkins RE and Fisher NR (1996) Beyond mere existence: The auditing of. Journal of Mental Health. 5, 3, 275-286. Reynolds JF et al (1992) Writing and Reading Mental Health Records. London, Sage. The Sainsbury Centre for Mental Health (1998) Acute Problems: A survey of the quality of care in acute psychiatric wards. London, The Sainsbury Centre for Mental Health. Shea HL (1986) A conceptual framework to study the use of nursing. International Journal of Nursing Studies. 23, 2, 147-157. Sheehan J (1991) Conceptions of the nursing process amongst teachers and clinical nurses. Journal of Advanced Nursing. 16, 332-342. Sheppard D (1996) Learning the Lessons (2nd edition). London, The Zito Trust. Siegal C and Fischer SK (1975) Psychiatric Records in Mental Health Care. New York, Brunner Publishers. Simonton MJ et al (1977) The open medical record: an educational tool. Journal of Psychiatric Nursing and Mental Health Services. December, 25-30. Teggart LM (1993) Measurement of care planning. Journal of Clinical Nursing. 2, 63-65. Thomas B (1996) Rethinking acute inservice user care. Australian and New Zealand Journal of Mental Health Nursing. 5, 32-39. Thomas B (1999) Care planning and documentation in mental health nursing. Mental Health Practice. 3, 1, 8-10. UKCC (1993) Standards for Records and Record Keeping. London, United Kingdom Central Council for Nursing, Midwifery and Health Visiting. UKCC (1998) Profession s Guidelines for Records and Record Keeping. London, United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Yassin T and Watkins S (1993) What influences care planning nurses attitudes towards. Professional Nurse. June, 572-577. assessment; identification of problems and needs; goal setting; identifying interventions; continuous record/progress notes; evaluation and review. Assessment assessment is often associated with information gathering and the completion of an assessment tool. However, assessment is an ongoing and dynamic process involving prioritising and goal setting. It is purposeful, focused and of therapeutic benefit to the client. A client-centred assessment will focus on the client s perspective, experience and perception of his or her circumstances. Used skilfully, the process of assessment engages the client and their carers in the development of a plan of care. It may include: History of current situation. Reasons for, and understanding of, hospital admission. Previous history health and illness. Effect of illness on social roles and relationships. Worries and concerns. Stressors. Strengths, skills and resources. Coping styles and strategies. Work, employment and occupational activities. Recreational interests, enjoyable pastimes, play and pleasure. Achievements, goals and aspirations. Self care skills and abilities. Access to services. Satisfaction with services. Assessment is used to define problems and needs from the client s perspective and set priorities in care. The aim of assessment is to gain the information necessary and sufficient to arrive at an understanding of the client s difficulties and formulate a plan of care (Newall 1994). An assessment carried out with the client paves the way for implementation of the plan by providing opportunities to engage the client in the process of care. Assessment involves the initiation of a therapeutic relationship between nurse and client. Identifying problems and need Assessment involves identification of both problems and needs. Nursing often use the terms interchangeably with Problem/Need headings. Problems and needs may be related directly problems caused by unmet need. However, it may not be so straightforward in practice. Problems may arise despite the needs of the individual, for example, when the nature and severity of mental illness involves the risk of violence to others. Problems for the individual client may arise because of the healthcare system. For many people, the experience of hospital admission is, itself, distressing. The needs of the individual client may be compromised by a range of factors, including the level of social support, access to services, appropriate treatment and care. Clients will be admitted to acute inpatient units with a wide range of problems and needs. It is neither possible nor appropriate to address all of these at once. It will be necessary to prioritise problems and needs for the period of admission. The reason for admission and associated factors or circumstances may provide a focus for the process of setting priorities in care. Problems and needs may be prioritised in relation to: the client perspective; resources including available services and interventions; the risk of harm to self, to others, and of self-neglect. Urgent problems and needs may be those associated with risk of harm to self and others, and self neglect that need to be addressed immediately. An urgent problem may have been resolved by hospital admission. Problems and needs may be important but not urgent. Perception of importance and urgency will vary according to individual attributes and characteristics, circumstances, timing, information and resources. TIME OUT 6 Prioritising problems and needs: Urgency Having carried out an assessment and identified problems and needs with the client, use the grid to prioritise problems and needs in terms of importance and urgency. Agree which problems and needs will be the focus of the care plan for this admission. High Medium Low Low Importance Medium Goals, objectives and outcomes High The goal of care is the end point or broad outcome that one strives to attain. Goals identify the desired outcome associated with health gain for the client, i.e. a client-centred outcome. The identification of goals is part of a purposeful therapeutic process established within the context of the nurse client relationship. Goals convey what it is that is to be achieved. The achievements of specific goals may represent improvements in other areas of functioning. Objectives are often used in care planning. These may be steps towards a goal or components of goals. Objectives may focus on a reduction in the incidence of a problem or need. They should be practically achievable, given the time and resources available. Ideally, goals and objectives represent a change desired by the client. In order to identify desired outcomes, it may be helpful to consider, What do I (the nurse) expect to see or do and/or what do I (the service user) expect to see or do as a consequence of the intervention? The outcomes of care specify the end result or desired improvement need to be observable, measurable or quantifiable in some way. For example, a change in the rate or frequency of a particular 36 MENTAL HEALTH PRACTICE NOVEMBER 2000 VOL 4 NO 3

behaviour. Outcomes need to be identified and recorded prior to interventions being carried out. Jenkins (1990) suggests this process involves: 1) Assessment and identification of individual problems and needs. 2) Precise definition of goals, objectives, outcomes or targets. 3) A review of available resources, strategies and interventions. The process of setting goals, objectives and outcomes can be both therapeutic and evaluative. This is particularly so, if they: are desirable to the client; are negotiated between the client and the nurse; indicate a commitment to change; clarify complex problems; relate to long-term improvement. Interventions are the actions that will be implemented in order to reach the goal. Once the goals are agreed, the interventions the possible and likely means of achieving the goals can be identified. The identification of appropriate interventions involves clarity about the results you hope to obtain. Interventions should be consistent with the goal. They should be: client centred; achievable; evidence based; oriented to health need or gain. The identification of planned, regular interventions in the care plan promotes consistency and continuity in the approach to care. The rationale and purpose for the intervention, i.e. why is it required, should be identified, along with who will implement it, and when. A review date should be set. Evaluation This focuses on all components of the plan, i.e. the interventions, the outcome of interventions in relation to the goals, and achievement of goals. You may evaluate whether or not interventions are being implemented and whether goals are being achieved. The effectiveness of interventions is determined by identifying evidence that the desired results have been achieved the demonstration that the client has accepted, used or otherwise benefited, from the intervention. Clearly, merely recording interventions that have been carried out is, in itself, not sufficient. Interventions must be evaluated against the expected outcome or goal of care. Evaluation of interventions involves consideration of continuing the effort, and of the feasibility of trying different interventions. It may involve a re-assessment of the original problem. The initial assessment set out a baseline of comparative information a measurement against which evaluative judgements about planning and implementation of the plan may be made. Now do Time Out 7. Conclusion This article promotes the use of the care plan as a therapeutic tool that can be used more effectively on acute units. The relationship between different elements of the care plan should be clear, with continuity and consistency across problems and needs, care goals and objectives, interventions, outcomes and evaluation. Box 4. Tools for composing care plan statements Writing problem statements It may be helpful to write a care plan statement that links the problem to any causative, or triggering, factors, along with the main effects or result. Gordon (1997) identifies a structure or template for this type of statement, referring to it as a PES problem statement format. The problem (P) is caused by (E) which results in (S) This statement identifies the health problem (P), key etiologic or related factors (E) and any defining characteristics, signs or symptoms (S). For example: John s anger is caused by his difficulty in talking about how he feels, which leads to him taking his aggression out on those he is close to, for example, his wife Mary. Alternatively use the service user s own words to describe the problem: For example, John says: I just can t help myself, nobody listens to me and I don t know what to do. I never meant to hurt her. Writing objective statements Objective statements have three main components: The desired or observable activity or behaviour; The conditions the circumstances under which the behaviour or activity takes place, for example, the amount, frequency, or duration; Criterion the level, quality or standard on the objective behaviour. Behavioural objectives focus on the desired or objective behaviour as an outcome: Who (subject) will do what (behaviour) under what circumstances (conditions) to what degree of success (criterion). For example, John will approach his key worker when he feels frustrated and begins to get angry and use anger management techniques he has identified to control his feelings safely. Expressive objectives focus on processes of verbal or intellectual activity, rather than the observable behaviour as an outcome: Who (subject) will do what (verbal or intellectual activity) under what circumstances (conditions). For example, John will meet with his key worker to discuss his angry feelings and appropriate ways of dealing with them. A less prescriptive use of these statements may be used, for example, replacing Who will do what with... has agreed to..., or...wants to.... Writing SMART statements Statements in share the qualities of SMART statements. These are Specific, Measurable, Achievable, Realistic, and Time bound. TIME OUT 7 With a colleague, as part of your clinical supervision, focus on a care plan you are using. Identify whether any of the issues identified in the section, Common problems with care plan statements apply to your care plan. Use the tools in Box 4 to review and rewrite the care plan. When you feel confident, take the care plan to the client and include him or her in the process. Service users and their carers should be involved in care planning, with the assessment phase used as a means of initially engaging them in this process. The importance of the care plan as a legal document is emphasised and standards for record keeping reinforced as a routine component of professional practice. Practical suggestions and guidance for writing more effective and accurate records have been provided as a means of improving clinical practice. NOVEMBER 2000 VOL 4 NO 3 MENTAL HEALTH PRACTICE 37