Salveo HomeCare - My Care Plan V2

My Care Plan
Care Partner Email
example@example.com
This care plan has been developed to align with your current health, goals, preferences, and support needs. Your voice, choices, and lived experience are central to shaping how your care is delivered. This care plan outlines the services and supports in place to help you live the life you choose at home, in your community, and on your own terms.
This Care Plan was created collaboratively, in partnership with you, and reflects our commitment to CARE values.

C–COMPASSION ensuring compassion extends to both our customers and our dedicated staff.

A–ADAPTABILITY be aware of different needs and preferences of our customers and delivering services in accordance with those needs

R–RESPECTevery customer is unique, and we value their individuality, diversity and choices

E–EMPOWERING improving the quality of life of every customer and engaging them in every decision that affects their care
This Care Plan Is For:
Full Name*

First NameLast Name
Preferred Name*
Date of this Care Plan*

DayMonthYear
Date
Purpose of this Care Plan*
Version of Care Plan
e.g. second care plan = version 2.
My Aged Care Reference ID*
Date of Birth*

DayMonthYear
Date
Phone Number*
Care Recipient or Representative's Email*
of the person signing the care plan - e.g. MPOA's email if applicable
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Gender Identity*
Place of Birth*
Aboriginal or Torres Strait Islander?*

NoYes, AboriginalYes, Torres Strait IslanderYes, both
Cultural Background*
Preferred Language/s*
Is an interpreter required?

YesNo
Things To Consider About My Cultural, Diversity, Values and Belief*
My care worker preferences?*

FemaleNo preferenceMale
My care worker, communication and service delivery preferences*
Important things i need my care workers to know when communicating with or delivering services to me.
Package Level*
Care Management Type*
Applicable Supplements or Additional Funding*
Is additional support or the use of remaining funds from the home care package needed?*

YesNo
Comments
additional support
Person Responsible for making decisions: *
People involved in developing My Care Plan:*
Specify name and relation to the Care Recipient. Separate by comma, e.g. Jane Doe - Daughter, John Doe - Son
If there is a Guardian or Power of attorney, a copy of the power of attorney paperwork has been provided*

YesNoNot applicable
Comments
Guardian or Power of attorney
Is there an Advance Care Directive in place?*

YesNoNot advised
Comments
Guardian or Power of attorney
My Preferred Support People

	Name	Role/Relation	Contact Number
Person #1
Person #2
Person #3
Person #4

Important Things To Know About Me
Family Background and Life History
OLD - Life History
Interests
Informal Supports*
Medical Information
My Medical History
Allergies and Alerts*
Include the reaction if know. Type Significant allergies or alerts in CAPS LOCK. Separate by comma, e.g. ANAPHYLAXIS TO DAIRY, allergy to nuts, WANDERER
Is medication required?*

YesNo
Is prompting needed?

YesNo
Is assistance needed?

YesNo
Is medication administration needed?

YesNo
Details of medication assistance needed
If applicable
Is there medication management plan in place?

YesNo
Upload a copy of the medication management plan

Cancelof

My Goals
How many goals does the client have?*

123456789101112131415
Goal 1
Goal 1
Abilities and Considerations (Risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 1 Review Date

DayMonthYear
Goal 1 Review Reminder Date

DayMonthYear
OFFICE USE ONLY - 2 weeks before the review is due
Goal 1 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Outcome (findings of assessment)
Recommendations

OLD Goal 1

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 2
Goal 2
Abilities and Considerations (Risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 2 Review Date

DayMonthYear
Goal 2 Review Reminder

DayMonthYear
OFFICE USE ONLY - 2 weeks before the review is due
Goal 2 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Outcome
Recommendations

OLD Goal 2

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 3
Goal 3
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 3 Review Date

DayMonthYear
Goal 3 Review Reminder

DayMonthYear
OFFICE USE ONLY - 2 weeks before review date
Goal 3 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Outcome
Recommendations

OLD Goal 3

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 4
Goal 4
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 4 Review Date

DayMonthYear
Goal 4 Review Reminder

DayMonthYear
OFFICE USE ONLY - 2 weeks before the review is due
Goal 4 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Outcome
Recommendations

OLD Goal 4

	Details
What do I want to achieve?
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 5
Goal 5
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 5 Review Date

DayMonthYear
Goal 5 Review Reminder

DayMonthYear
OFFICE USE ONLY - 2 weeks before the review is due
Goal 5 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Outcome
Recommendations

OLD Goal 5

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 6
Goal 6
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 6 Review Date

DayMonthYear
Goal 6 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 6 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Outcome
Recommendations

OLD Goal 6

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 7
Goal 7
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 7 Review Date

DayMonthYear
Goal 7 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 7 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations

OLD Goal 7

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 8
Goal 8
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 8 Review Date

DayMonthYear
Goal 8 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 8 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations

OLD Goal 8

	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Goal 9
Goal 9
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 9 Review Date

DayMonthYear
Goal 9 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 9 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Goal 10
Goal 10
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 10 Review Date

DayMonthYear
Goal 10 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 10 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Goal 11
Goal 11
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 11 Review Date

DayMonthYear
Goal 11 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 11 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Goal 12
Goal 12
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 12 Review Date

DayMonthYear
Goal 12 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 12 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Goal 13
Goal 13
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 13 Review Date

DayMonthYear
Goal 13 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 13 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Goal 14
Goal 14
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 14 Review Date

DayMonthYear
Goal 14 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 14 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Outcome
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Goal 15
Goal 15
Abilities and considerations (risks)
How will we do this? (Tasks)
Who is responsible?
When will it be done? (time, day, frequency)
How much will it cost?
Has this goal been achieved? (Status)

YesNoIn Progress
Comments (in relation to status)
Start Date

DayMonthYear
Goal 15 Review Date

DayMonthYear
Goal 15 Review Reminder

DayMonthYear
OFFICE USE ONLY
Goal 15 Review
Date of Review

DayMonthYear
Date Completed

DayMonthYear
Has this goal been achieved? (Status)

YesNoIn Progress
Recommendations
Outcome

	Applicable?	Details
Care Management
Living Companion
Personal Care
Domestic Assistance
Nursing Care
Home and Garden Maintenance
Social Support
Transport
Allied Health Services
Continence Management
Skin integrity
Medication Management or Assistance
Meal Management or Assistance
Activities of daily living
Memory
Cognition
Falls Frequency
Communication
Personal Alarm
Financial Management
Behaviours

	Name	Role
1
2
3
4
5

My Care Plan

My Preferred Support People

Important Things To Know About Me

Medical Information

Risk Assessment

Falls Mobility

Medication Management

Personal Hygiene & Skin Integrity

Nutrition & Hydration

Social Isolation

Cognition & Memory (Dementia)

Abuse or Neglect

Home Environment Hazards

Natural Disaster

Financial Mismanagement

Mobility and Equipment

Emergency Contacts

1st Contact

2nd Contact

Preferred Doctor / Medical Centre

Additional Instructions for Support

My Goals

Goal 1

Goal 1 Review

Goal 2

Goal 2 Review

Goal 3

Goal 3 Review

Goal 4

Goal 4 Review

Goal 5

Goal 5 Review

Goal 6

Goal 6 Review

Goal 7

Goal 7 Review

Goal 8

Goal 8 Review

Goal 9

Goal 9 Review

Goal 10

Goal 10 Review

Goal 11

Goal 11 Review

Goal 12

Goal 12 Review

Goal 13

Goal 13 Review

Goal 14

Goal 14 Review

Goal 15

Goal 15 Review

Budget

Care Plan Consent and Distribution

Prepared By