We still do monthly summaries. Is the front a check list, like an assessment of different areas? The back for narritive notes should address the care plan or you have no way of showing your reviewing it to see if it's working.
Example: Care Plan #2
At risk for skin break down
The resident is compliant with turning and positioning. Orders include VitC and Zinc, tolerates well. Resident on toileting program and is provided peri care after incont. episodes. Using a BSC at night. Intake 75-100% ect.......
Continue current plan of care.
This is tour oppertunity to address with the care plan team if a care plan could be D/Cd or added or changed.
Did the resident meet the goals of the care plan?
Are they clear and realistic?
Do they need to be revised?
Address each care plan.