What is a Care Plan?

A Care Plan may be referred to by a few different names: Support Plan, Services Plan, or Nursing Care Plan.  Essentially, these names are referring to the same thing: A plan that outlines a person’s health care needs, goals, and services. The plan also outlines which staff will provide those services as well as the frequency, duration, and timeline for completion.  

Care plans include, but are not limited to, the following:

• Prioritized goals for a client’s health status
• Established timeframes for reevaluation/recertification
• Resources that might benefit the patient, including a recommendation as to the appropriate level of care
• Planning for continuity of care, including assistance making the transition from one care setting to another including discharge planning
• Collaborative approaches to health, including family participation

A care plan should enhance person’s treatment by providing a list of identified health conditions or problems with a corresponding prioritized list of interventions to meet the person’s goals.

There is no single template that must be followed for creating a care plan, but there are critical elements that should be included.

The format will vary based on the provider’s charting process and electronic capabilities.

The care plan format should fit into the provider’s current workflow and make sense to family members, caregivers, and other agencies who need to access it.

Care plans should be developed collaboratively between the client, family members, and healthcare staff.

Care plans should meet CMS (Center for Medicare & Medicaid Services), OCR (Office of Civil Rights), Joint Commission, and accreditation organization requirements.  The conditions of participation (CoPs) in these programs must be met and maintained.

Have more questions about Care Plans? Feel free to contact us for additional questions.