Aged Care Individual Care Plan: Key Points

  • An Individual Care Plan (ICP) is a comprehensive document that guides personalized care delivery for aged care residents or home care clients.
  • Care plans must include health assessments, functional evaluations, psychosocial needs, medication management, and care goals.
  • Regular reviews (minimum every 12 months or when condition changes) ensure care remains appropriate and effective.
  • Care plans must be developed in consultation with the client, family, and multidisciplinary care team.

Download Our Free Aged Care Individual Care Plan Template

We’ve created a comprehensive, person-centered care plan template that meets aged care standards:

Download Aged Care Individual Care Plan Template (DOCX)

This template includes:

  • Client demographics and emergency contacts
  • Comprehensive health status assessment
  • Current medications chart
  • Functional ability assessment across all activities of daily living
  • Psychosocial and emotional needs evaluation
  • Personalized care goals with action plans
  • Risk assessment and management strategies
  • Service delivery schedule
  • Signature and consent sections

What is an Aged Care Individual Care Plan?

An Individual Care Plan (ICP) is a detailed, person-centered document that outlines the specific care and support needs of an aged care client. It serves as the primary guide for all care staff, ensuring consistent, coordinated, and personalized care delivery.

The Individual Care Plan serves multiple critical purposes:

  • Personalized care: Ensures care is tailored to individual needs, preferences, and goals
  • Communication tool: Provides clear guidance to all staff involved in care delivery
  • Quality assurance: Demonstrates compliance with aged care standards and regulations
  • Continuity of care: Ensures consistent care across different staff and shifts
  • Accountability: Creates a documented record of planned and delivered care

Essential Components of an Aged Care Individual Care Plan

A compliant and effective care plan must include these key elements.

1. Client Details and Background

  • Full legal name and preferred name
  • Date of birth and age
  • Residential address or room number
  • Contact details
  • Next of kin and emergency contacts
  • GP and medical practitioners
  • Medicare and private health insurance details
  • Cultural, religious, and language preferences

2. Health Status and Medical Conditions

Document all current health conditions:

  • Primary diagnoses and medical history
  • Chronic conditions (diabetes, heart disease, COPD, etc.)
  • Cognitive status (dementia, memory impairment)
  • Mental health conditions (depression, anxiety)
  • Sensory impairments (vision, hearing)
  • Dental and oral health status
  • Wound care needs
  • Continence status

3. Current Medications

Comprehensive medication documentation:

  • Medication name and strength
  • Dosage and frequency
  • Route of administration
  • Prescribing doctor
  • Purpose/indication
  • Special instructions (with food, avoid grapefruit, etc.)
  • PRN (as needed) medications with specific instructions
  • Recent medication changes or ceased medications

4. Functional Assessment

Evaluate ability across all activities of daily living:

Personal Care

  • Showering/bathing (independent, supervision, assistance, dependent)
  • Oral care and denture management
  • Hair care and grooming
  • Dressing and undressing
  • Continence management
  • Skin care needs

Mobility and Transfers

  • Walking and ambulation
  • Use of mobility aids (walker, cane, wheelchair)
  • Bed transfers
  • Chair transfers
  • Toilet transfers
  • Fall risk assessment

Eating and Nutrition

  • Eating ability (independent, assistance needed)
  • Dietary restrictions or requirements
  • Texture modifications (pureed, minced, soft)
  • Fluid thickness requirements
  • Swallowing difficulties (dysphagia)
  • Nutritional supplements

Communication

  • Verbal communication ability
  • Hearing aids or assistive devices
  • Vision aids (glasses, magnifier)
  • Preferred language
  • Communication barriers

Cognitive Function

  • Memory and recall
  • Decision-making capacity
  • Orientation to time, place, person
  • Following instructions
  • Safety awareness

5. Psychosocial and Emotional Needs

Understanding the whole person:

  • Social connections and relationships
  • Family involvement and visiting patterns
  • Hobbies, interests, and pastimes
  • Previous occupation and life roles
  • Cultural and spiritual practices
  • Emotional wellbeing and mood
  • Social engagement preferences
  • End-of-life wishes and advance care directives

6. Care Goals

Develop SMART goals collaboratively:

Types of Care Goals

  • Maintenance goals (maintain current function)
  • Improvement goals (increase independence)
  • Comfort goals (manage symptoms, enhance quality of life)
  • Social goals (increase engagement, build relationships)
  • End-of-life goals (dignity, comfort, wishes honored)

For Each Goal Include:

  • Specific, measurable objective
  • Actions and interventions to achieve the goal
  • Who is responsible (nursing, allied health, lifestyle, family)
  • Target date or review timeframe
  • Progress indicators

Example Goal:

  • Goal: Improve mobility and reduce fall risk
  • Actions: Physiotherapy 2x weekly, install grab rails in bathroom, encourage use of walking frame, supervise all transfers
  • Responsible: Physiotherapist, maintenance team, all care staff
  • Target: Review in 3 months
  • Indicators: No falls, increased confidence with walking frame, improved balance scores

7. Risk Assessment and Management

Identify and manage potential risks:

Falls Risk

  • Previous falls history
  • Mobility limitations
  • Environmental hazards
  • Management strategies (supervision, equipment, exercise)

Pressure Injury Risk

  • Skin integrity assessment
  • Mobility and repositioning needs
  • Nutrition status
  • Prevention strategies (pressure relief, skin care, nutrition)

Medication Risks

  • High-risk medications
  • Polypharmacy concerns
  • Self-administration capacity
  • Management strategies (Webster packs, supervision, regular reviews)

Nutrition and Hydration Risks

  • Weight loss or malnutrition
  • Dehydration risk
  • Swallowing difficulties
  • Management strategies (monitoring, supplements, referrals)

Infection Control

  • Susceptibility to infections
  • Chronic wounds
  • Indwelling devices
  • Prevention strategies (hand hygiene, wound care, immunizations)

Behavioral and Psychological

  • Wandering or absconding risk
  • Responsive behaviors (aggression, agitation)
  • Self-harm or suicidal ideation
  • Management strategies (triggers, de-escalation, activities)

8. Care Services and Interventions

Detail all care to be provided:

Daily Care Services

  • Personal hygiene assistance (shower, oral care, grooming)
  • Continence care and toileting assistance
  • Dressing and grooming support
  • Meal preparation and feeding assistance
  • Medication administration
  • Mobility assistance and transfers

Clinical Services

  • Wound care and dressing changes
  • Catheter or PEG care
  • Blood glucose monitoring
  • Blood pressure monitoring
  • Weight monitoring
  • Oxygen therapy

Allied Health Services

  • Physiotherapy frequency and focus
  • Occupational therapy interventions
  • Speech pathology (swallowing, communication)
  • Podiatry care
  • Dietitian consultations

Lifestyle and Social Programs

  • Group activities participation
  • One-on-one activities
  • Outings and excursions
  • Spiritual and religious support
  • Volunteer programs

9. Family and Carer Involvement

  • Preferred level of family involvement
  • Communication preferences with family
  • Tasks family wishes to continue (e.g., showering, feeding)
  • Family support needs
  • Decision-making arrangements

10. Review and Monitoring

  • Care plan creation date
  • Last review date
  • Next scheduled review (minimum annually)
  • Triggers for earlier review (hospitalization, falls, condition changes)
  • Who will participate in reviews (client, family, GP, care team)

How to Create an Aged Care Individual Care Plan

Step 1: Conduct a Comprehensive Assessment

Before creating the care plan:

  • Review all available medical records and referral information
  • Conduct health and functional assessments
  • Interview the client about preferences, goals, and concerns
  • Speak with family members (with client consent)
  • Consult with GP and specialists
  • Observe the client in their environment
  • Review current medications and treatments

Step 2: Identify Care Needs and Priorities

Analyze assessment information to determine:

  • Immediate care needs and safety concerns
  • Ongoing support requirements
  • Goals for maintaining or improving function
  • Preferences for care delivery
  • Cultural and spiritual considerations
  • Risk factors requiring management

Step 3: Develop Person-Centered Goals

Work collaboratively with the client and family to set goals that:

  • Reflect the client’s values and preferences
  • Are realistic and achievable
  • Focus on quality of life, not just medical needs
  • Consider both physical and psychosocial wellbeing
  • Include maintenance, improvement, or comfort goals as appropriate

Step 4: Plan Interventions and Services

For each identified need, determine:

  • What services or interventions are required
  • How often services will be provided
  • Who will deliver each service
  • What equipment or resources are needed
  • How effectiveness will be measured

Step 5: Assess and Plan for Risks

For each identified risk:

  • Rate the level of risk (low, medium, high)
  • Identify contributing factors
  • Develop specific management strategies
  • Assign responsibility for monitoring
  • Set review dates

Step 6: Document the Care Plan

Write the care plan in clear, accessible language:

  • Use person-first language (“Mrs. Smith prefers” not “the resident requires”)
  • Be specific about frequency, timing, and approaches
  • Include both clinical and personal care needs
  • Document preferences and choices
  • Note any advance care directives or end-of-life wishes

Step 7: Review and Approve

Before implementing:

  • Review the draft care plan with the client
  • Discuss with family members (with consent)
  • Seek input from the multidisciplinary team
  • Make any requested adjustments
  • Obtain client signature and consent
  • Distribute to all relevant care staff

Step 8: Implement and Monitor

Put the care plan into action:

  • Communicate the care plan to all staff involved in care delivery
  • Ensure all staff understand their responsibilities
  • Monitor care delivery against the plan
  • Track progress towards goals
  • Document any variations or concerns
  • Respond promptly to changing needs

Step 9: Review Regularly

Conduct formal reviews:

  • At least every 12 months
  • When the client’s condition changes significantly
  • After hospitalization or acute illness
  • When goals are achieved or no longer relevant
  • At client or family request
  • When care services change

Best Practices for Aged Care Individual Care Plans

Focus on the Whole Person

  • Look beyond medical conditions to understand the person’s life story
  • Include interests, hobbies, and what brings joy
  • Respect cultural, spiritual, and religious practices
  • Consider relationships and social connections
  • Honor preferences and choices

Involve the Client and Family

  • Make care planning a collaborative process
  • Respect the client’s autonomy and right to choose
  • Listen to family insights and concerns
  • Communicate in accessible language
  • Provide time for questions and discussion

Keep It Current

  • Update the care plan whenever circumstances change
  • Document changes promptly
  • Communicate updates to all staff
  • Review regularly, don’t wait for the annual review
  • Respond to feedback from clients, families, and staff

Make It Practical and Usable

  • Write in clear, specific language that staff can follow
  • Include enough detail for consistency
  • Make it easy to find information quickly
  • Use a logical, organized format
  • Ensure it’s accessible to all staff (not locked away)
  • Connect care activities to specific goals
  • Track and measure progress
  • Celebrate achievements
  • Adjust when goals aren’t being met
  • Demonstrate value and effectiveness of care

Aged Care Standards and Care Planning

The Aged Care Quality Standards require person-centered care planning.

Standard 1: Consumer Dignity and Choice

Care plans must:

  • Reflect the consumer’s choices and preferences
  • Support independence and autonomy
  • Respect cultural, spiritual, and linguistic needs
  • Include advance care directives

Standard 2: Ongoing Assessment and Planning

Care plans must:

  • Be based on comprehensive assessment
  • Be developed in partnership with the consumer
  • Be reviewed regularly
  • Be updated when needs change

Standard 3: Personal Care and Clinical Care

Care plans must:

  • Detail all personal care and clinical care needs
  • Include appropriate interventions
  • Identify risks and management strategies
  • Ensure safe, effective care delivery

Standard 8: Organizational Governance

Care plans must:

  • Be developed by appropriately qualified staff
  • Be approved by registered nurses or medical practitioners
  • Be accessible to all staff providing care
  • Be monitored and evaluated for effectiveness

Common Care Planning Challenges and Solutions

Challenge: Client Has Dementia and Cannot Participate

Solution:

  • Involve family members who know the client well
  • Review life history and previous preferences
  • Observe the client’s responses to different approaches
  • Focus on comfort, dignity, and quality of life
  • Update the plan as you learn what works

Challenge: Complex Medical Needs Overwhelm the Plan

Solution:

  • Organize by body system or care domain
  • Use clinical pathways for common conditions
  • Summarize key information at the front
  • Create quick reference guides for complex care
  • Ensure staff have access to detailed protocols

Solution:

  • Listen to family concerns without being defensive
  • Explain clinical reasoning and evidence base
  • Explore compromise solutions
  • Involve the GP or specialists in discussions
  • Document decisions and reasons
  • Respect the client’s choices (if they have capacity)

Challenge: Care Plan Becomes Outdated Quickly

Solution:

  • Set up a system for regular mini-reviews
  • Empower staff to flag changes as they occur
  • Use electronic systems that make updates easy
  • Assign responsibility for keeping plans current
  • Build a culture of continuous updating

Frequently Asked Questions

Who is responsible for creating the care plan? A registered nurse or appropriately qualified care coordinator typically develops the care plan, with input from the client, family, GP, and multidisciplinary team.

How often must care plans be reviewed? At minimum, annually. However, they should be reviewed whenever the client’s condition or needs change significantly.

Can a client refuse to have a care plan? While care plans are required for accreditation, the client has the right to choose not to participate. Document this choice and develop the plan based on available information and professional judgment.

What if the client’s family wants care that’s not recommended? Discuss concerns openly, explain clinical reasoning, and seek compromise. If agreement can’t be reached, document the discussion and the client’s/family’s choice. Involve the GP or ethics committee if needed.

How detailed should a care plan be? Detailed enough that any staff member can provide consistent, appropriate care, but not so detailed it becomes unmanageable. Focus on what’s essential and variable.

Can care plans be electronic? Yes. Many facilities use electronic care planning systems. Ensure all staff can access them and that there’s a backup for system failures.

Summary

Individual Care Plans are the foundation of quality aged care. A well-developed plan ensures personalized, consistent, and effective care that honors the client’s dignity, preferences, and goals.

Key takeaways:

  • Conduct comprehensive assessments before developing care plans
  • Involve clients and families in the planning process
  • Include all domains: health, function, psychosocial, and risk management
  • Set realistic, person-centered goals
  • Review and update plans regularly
  • Make plans practical and usable for all staff
  • Ensure compliance with Aged Care Quality Standards
  • Focus on quality of life, not just medical needs

Download our free aged care individual care plan template to create comprehensive, person-centered care plans.

Download Aged Care Individual Care Plan Template (DOCX)