Behavioral Care Plan (Dementia-Related Behaviors/BPSD)

Plan Type: [Initial / Update / Post-Incident Revision]

Date Created: [Date]   Effective Date: [Date]

Setting: [home / assisted living / SNF / inpatient]; [Unit/Room if applicable]

Author: [Name, Role, Discipline]

Plan Owner: [Role or person responsible for plan maintenance]

Primary Contacts: [Family/POA/guardian names, relationship, phone, preferred language]

Intended Users: [Roles this plan is written for]

Resident Participation: [yes / no / limited]; [Brief explanation if limited]

Representative Involvement: [Name, relationship, participation status]

Quick Start Summary

• Target Behaviors (Prioritize 3–5)
  • [Operational label] — Risk: [low / moderate / high]; Timing: [When/where behavior typically occurs]
  • [Operational label] — Risk: [low / moderate / high]; Timing: [When/where behavior typically occurs]
  • [Operational label] — Risk: [low / moderate / high]; Timing: [When/where behavior typically occurs]
• What Works (Top 3 approaches; use imperative verbs)
  • [Effective approach #1]
  • [Effective approach #2]
  • [Effective approach #3]
• What to Avoid (Top 3 contraindications)
  • [Contraindication #1]
  • [Contraindication #2]
  • [Contraindication #3]
• Safety Instructions
  • Stop and escalate if: [Clear threshold #1]; [Clear threshold #2]; [Clear threshold #3]
  • First contact: [Role/Name and number]; After-hours: [On-call contact and instructions]
  • Absolute contraindications: [Actions that must never occur]

Patient Context

• Dementia Summary
  • [Dementia diagnosis and subtype]
  • [Cognitive/communication level relevant to care]
  • [Mobility status and fall risk considerations]
  • [Sensory factors and device availability]
• Personal Profile
  • [What matters most to this person relevant to care]
  • [Preferences and aversions for caregiving tasks]
  • [Calming cues and effective reinforcers]
  • [Information still needed and who will obtain it] (Include only if applicable)

Assessment Summary

(Include when plan is new or behaviors have changed)

• Modifiable Contributors Evaluated
  • Pain/discomfort: [Checked: yes / no]; [Findings]; [Actions/Pending]
  • Acute medical changes: [Checked: yes / no]; [Findings]; [Actions/Pending]
  • Medication contributors: [Checked: yes / no]; [Findings]; [Actions/Pending]
  • Sleep disruption: [Checked: yes / no]; [Findings]; [Actions/Pending]
  • Sensory impairment/devices: [Checked: yes / no]; [Findings]; [Actions/Pending]
  • Environmental factors: [Checked: yes / no]; [Findings]; [Actions/Pending]
  • Task/care approach mismatch: [Checked: yes / no]; [Findings]; [Actions/Pending]
• Working Hypothesis
  • Observed patterns: [Documented triggers, timing, and measured data]
  • Clinical interpretation: [Behavior appears triggered by X and may serve to Y] (Use cautious language; separate facts from interpretation)
  • Concerns requiring clinician notification: [Concern for X; notify clinician] (Do not diagnose new medical problems)

Risk Assessment

• Risk Domains
  • Harm to others: [Present / Absent / Unknown]; [Examples]
  • Self-harm/accidental self-injury: [Present / Absent / Unknown]; [Examples]
  • Elopement/wandering: [Present / Absent / Unknown]; [Examples]
  • Sexual disinhibition: [Present / Absent / Unknown]; [Examples]
  • Fire/weapon risk: [Present / Absent / Unknown]; [Examples]
  • Falls linked to agitation: [Present / Absent / Unknown]; [Examples]
• Protective Factors: [Factors that help—responds to validation, preferred staff, calming activities]
• Restrictive Interventions: [If used: specific indication, least restrictive alternatives attempted, monitoring requirements] (If none: "No restrictive interventions planned; use de-escalation pathway")

Behavior-Specific Support Plans

(Create a separate block for each target behavior)

Behavior [#]: [Operational label]

• Definition and Baseline
  • Operational definition: [What counts with 2–3 examples]; Does not include: [What does not count]
  • Measurement period: [Date range]
  • Baseline: Frequency [#/period]; Duration [average/range]; Severity [scale or description]
  • Impact: [Injury / care refusal / distress / disruption]
• Triggers and Warning Signs
  • Antecedents/Triggers [Observed / Reported / Suspected]: [List common triggers]
  • Early warning signs [Observed / Reported / Suspected]: [Observable signals]
  • Setting events [Observed / Reported / Suspected]: [Factors that increase likelihood]
• Prevention Strategies (Write as when-do instructions with imperative verbs)
  • Routine modifications: [Timing/order of tasks that work better]
  • Communication approach: [Prompt style, wait time, validation phrases]
  • Environment: [Modifications to reduce triggers]
  • Engagement: [Activity matched to ability, preferred items]
  • Comfort: [Toileting schedule, hydration, rest, pain measures]
  • Staffing: [Preferred staff, caregiver limits, gender preference]
  • Explicit contraindications: [What to avoid for this behavior]
• De-escalation Pathway
  • Early escalation: [Validate emotion] → [Reduce demands] → [Offer two choices] → [Redirect to preferred activity]
  • Moderate escalation: [Increase personal space] → [Reduce stimuli or relocate] → [Call for support: specify who]
  • High escalation/imminent harm: [Safety positioning] → [Remove bystanders] → [Emergency response] → [PRN per order only after behavioral steps attempted]
  • Scripted phrases:
    • [De-escalation phrase #1]
    • [De-escalation phrase #2]
• After Episode
  • Immediate: [Steps to restore calm and ensure safety]
  • Documentation: [ABC elements, intervention used, response, injuries]
  • Re-attempting care task: [When, how, and who should lead retry]
• Review Triggers
  • [New injury or property damage]
  • [Increasing frequency/severity or new pattern]
  • [Sudden change from baseline]
  • [Repeated PRN use beyond threshold]
  • [Intervention failure over defined period]

Medication Coordination

(Include when psychotropic or behavior-relevant medications are in use; if none: "No behavior-relevant medications in use")

• Current Relevant Medications
  • [Medication name] — [Dose, schedule]; PRN parameters: [If applicable]; Indication: [Documented target symptom]; Start/last change: [Date]
  • (If indication unknown: "Indication not found in record; escalate to prescribing clinician for review")
• Nonpharmacologic Trials
  • [Intervention linked to target behavior] — [Response]
• Monitoring Plan
  • Watch for: [Sedation, orthostasis, EPS, worsening confusion, falls]
  • Metrics to track: [Behavior counts, PRN use frequency]
  • Contact clinician if: [Specific thresholds or adverse effects]

Monitoring and Review

• Data Collection
  • Who records: [Role(s)]
  • Where recorded: [Location/system]
  • Minimum data: [ABC elements, duration, intervention, outcome]
• Outcome Metrics (At least one per target behavior)
  • [Behavior]: [Metric—frequency, severity, PRN count, injury, care completion]
• Goals (Measurable with timeframe)
  • [Within X days, reduce/increase target behavior/outcome from baseline to goal]
• Review Schedule
  • Next review date: [Date]
  • Immediate review if: [Objective triggers]

Consistency Points

(List 2–4 non-negotiable rules all caregivers must follow)

• [Consistency rule #1]
• [Consistency rule #2]
• [Consistency rule #3]
• [Consistency rule #4]

(If information is unavailable for any required section, use "Unknown" or "Not available at time of writing" and assign follow-up with responsible party and timeframe)