From steps to a real case
A case is the true story of one person we care for. In practice we do not use the care process as a form to fill. We use it as a way to think and then write short lines that other people can use.
Our case: Mr. Kumar, 72. Three months ago he had a stroke. His right hand is weak, his speech is slow but clear, and he likes dal and rice. He lives with his son's family and eats alone in his room because he spills food. He says, "I want to sit at the table with my grandchildren."
Information gathering and assessment in the case
Facts we found by watching, asking him and asking the family:
- Body: right hand weak, left hand strong, can sit steadily.
- Mind: clear, sad at mealtimes.
- Home: dining table high, plain plate and thin spoon.
- People: family willing to help.
- Wish: eat at the table with family.
Assessment: strengths are the strong left hand, a clear mind and a loving family. The difficulty is a thin slippery spoon and a flat plate. The cause of eating alone is shame about spilling, not lack of hunger.
Life issues and goals in the case
Life issues: (1) cannot hold and use a spoon well, (2) feels lonely and ashamed at meals.
Long-term goal: eat dinner at the family table every day.
Short-term goal: in four weeks, eat half a plate of rice and dal with a spoon and spill only a little.
Notice that the goals use his own wish, they are clear and they have a time.
Care plan, implementation and record
| What | Who | How and when |
|---|---|---|
| Use a thick-handle spoon and rimmed plate | Care worker, son buys them | Every dinner |
| Practise scooping with the left hand | Mr. Kumar, worker beside him | 10 minutes before dinner |
| Family waits and talks, no hurrying | Family | At dinner |
A good record is short and true: date, what was done, how the person was, one fact that others should know. Example: "Mon: used thick spoon, spilled twice, said spoon is easier."
Evaluation and revision
After two weeks we compare with the start. Result: spills dropped from many to two, he ate with the family three times, he is smiling. The short goal is nearly reached. But he gets tired after 10 minutes and vegetables are hard to scoop.
Revise: cut vegetables smaller, put a rest break in the plan, and set a new goal: "eat the whole meal at the family table five days a week". The loop starts again.
Practical tips: stay honest, never write what you did not do, report big changes to the team at once.
Try it: write a mini plan
Think of a person who finds one daily thing hard (for example, buttoning a shirt). Write five lines: the fact, the issue, a goal with a time, one plan line (what, who, how, when) and one way you will check. Show it to the person and ask if the goal is really theirs.
Key formulas and definitions
- Case notes = Facts + Issue + Goal + Plan + Record + Review
- Plan line = What + Who + How + When
- Record = Date + what was done + how the person was + one thing to tell others
- Revise = compare with start, keep what works, change what does not
Worked examples
1. In Mr. Kumar's case, what is the cause of eating alone?
Shame about spilling food, not lack of hunger. Assessment finds this cause by listening to him.
2. Write one short-term goal for him in good form.
"In four weeks, Mr. Kumar eats half a plate of rice and dal with a spoon and spills only a little."
3. Write a good one-line record for a dinner.
"Tue: used thick spoon, practised 10 minutes, spilled once, ate with family, was cheerful."
4. After two weeks he tires after 10 minutes. How do you revise?
Add a rest break to the plan, cut food smaller, and keep the longer goal of finishing the meal at the table.
Common mistakes
- Copying the same plan for every person.
- Writing records that say only "fine" with no facts.
- Ignoring the person's own wish when it looks risky.
- Not revising the plan after the evaluation shows new needs.