Five AN-ACC starter templates.

mobility

Problem

Walks independently with no aid; no recent falls in the chart.

Goal

Resident remains falls-free over the review window.

Intervention

Recheck mobility each shift note; flag any new stumble within one shift.

skin

Problem

Skin intact, no pressure concerns at baseline.

Goal

Skin integrity preserved.

Intervention

Visual skin check at bath days; document any redness that does not resolve.

nutrition

Problem

Eats independently; weight stable within usual range.

Goal

Weight and hydration maintained within normal range.

Intervention

Monthly weight + offer fluids at every meal and activity.

mobility

Problem

Walks independently but uses a stick for community outings.

Goal

Resident remains falls-free while on anticoagulant therapy.

Intervention

Recheck mobility each shift; report any bruise, gait change or bleed to the RN within one shift.

skin

Problem

No breakdown; thin skin on forearms noted at baseline.

Goal

Skin intact; bruising documented.

Intervention

Skin check at morning wash; chart any new bruise with size and date.

nutrition

Problem

Eats independently; mild appetite variability at evening meal.

Goal

Weight maintained within 2 kg of baseline.

Intervention

Weekly weight; flag a 1 kg drop to RN within one shift.

mobility

Problem

Hoist transfers with two staff; no independent movement; recent pressure on the sacrum noted.

Goal

No new pressure injury; transfers completed without skin shear.

Intervention

Two-person hoist with slide sheet; log skin integrity after each transfer.

skin

Problem

Stage 1 redness on sacrum; existing pressure plan in place.

Goal

Healing pressure area; no new breakdown.

Intervention

Two-hourly reposition during waking hours; alternate mattress engaged; chart position each shift.

nutrition

Problem

Full assistance at meals; thin fluids prescribed for safe swallow.

Goal

Weight preserved and no aspiration events.

Intervention

Sit resident upright for 30 minutes after each meal; flag any cough or wet voice to RN within one shift.

mobility

Problem

Returned from hospital; uses a four-wheeled walker and one assist on flat ground.

Goal

Independent with walker on flat ground within 14 days.

Intervention

Daily supervised walk; escalate any near-fall to RN within one shift.

skin

Problem

No current breakdown; recent IV site bruising on right forearm.

Goal

IV site healed; no new breakdown.

Intervention

Daily check of the IV site until fully healed; chart and date any new bruise.

nutrition

Problem

Reduced appetite; small frequent meals preferred at present.

Goal

Appetite returns and weight stable within 2 kg.

Intervention

Offer mid-meal snacks; chart intake at each meal and escalate a 1 kg drop to RN within one shift.

mobility

Problem

Walks unaided; unfamiliar with air-lock layout of the home.

Goal

No falls while settling in over the first seven days.

Intervention

Walked orientation on arrival; escort to meals for the first three days; chart each mobility event.

skin

Problem

Skin intact on arrival; not previously seen at this service.

Goal

Baseline established and recorded.

Intervention

Full skin check on day one and at each weekly RN round; record photograph and date if a finding.

nutrition

Problem

Family confirms usual diet; allergies recorded but not yet observed.

Goal

Diet and allergy list confirmed within 24 hours.

Intervention

Confirm with family on arrival; escalate any reaction to RN within one shift.