What is the plan of care for a patient?

Plan of Care for a Patient

Every patient requires a structured, individualized care plan developed collaboratively by an interdisciplinary team that includes the patient as an active participant, documented in writing, and signed by all team members including the patient or their designee. 1

Core Components of the Care Plan

1. Comprehensive Patient Assessment

The assessment must document the following specific elements to inform treatment planning:

• Medical history including all chronic conditions, prior hospitalizations, and current medications with dosages and adherence patterns 2, 3
• Cardiovascular risk factors including tobacco, alcohol, and substance use screening 2
• Functional status including ability to perform activities of daily living and participate in vocational/recreational activities 1, 3
• Cognitive function and mental status 3
• Social determinants of health including economic security, transportation access, housing stability, food security, and social support systems 1, 2
• Patient's abilities, interests, preferences, and goals including desired level of participation in their own care 1
• Immunization status and preventive care needs 2

2. Collaborative Goal-Setting and Treatment Planning

The treatment plan must prioritize goals through patient-clinician partnership, with short-term achievable objectives based on what the patient wants to accomplish and feels confident they can achieve. 2, 3

Specific documentation requirements include:

• Prioritized goals with intervention strategies for risk reduction 3
• Medication management plan ensuring appropriate medications per clinical guidelines, with documented dosages, adherence monitoring, and allergy documentation 2, 3
• Self-management support strategies tailored to the patient's chronic conditions 2
• Action plans that sequence care when multiple competing issues exist 2
• Contingency planning for anticipated complications or disease progression 1

3. Advance Care Planning (When Appropriate)

For patients with serious illness, cognitive decline, functional decline, or those in care transitions, advance care planning is essential:

• Identify a surrogate decision-maker and document their relationship to the patient 1
• Explore patient values and priorities regarding quality of life and acceptable versus unacceptable health states 1
• Discuss prognosis honestly using clear, succinct language followed by silence to allow processing 1
• Document preferences for medical interventions, including completion of medical power of attorney and POLST forms when appropriate 1
• Address end-of-life care preferences including goals for comfort, dignity, and symptom management 1

4. Ongoing Monitoring and Follow-Up

Patients require periodic clinical evaluation with specific assessment intervals based on their conditions and treatments. 1

Follow-up must include:

• Reassessment of cardiovascular risk factors and adherence to medical therapy 1
• Evaluation of functional status changes and ability to participate in structured exercise programs 1
• Medication reconciliation at every encounter 2
• Monitoring for treatment complications specific to the patient's conditions and interventions 1
• Documentation of interval changes in symptoms, functional capacity, and quality of life 1

5. Team-Based Care Coordination

The interdisciplinary team must provide coordinated care with clear communication among all providers, the patient, and family members. 1

This includes:

• Regular team meetings to review progress toward goals 1
• Timely specialist referrals when clinical findings exceed primary care management scope 2
• Connection to community resources for social determinants of health needs 2
• Continuity across care settings with documented transition plans 1
• Assignment of a team member to maintain ongoing communication with patient and family 1

6. Special Considerations for Vulnerable Populations

For uninsured or underserved patients:

• Assume ongoing relationships rather than episodic care 2
• Systematically screen for social determinants including poverty, food insecurity, and transportation barriers 2
• Identify and connect patients to community resources and safety-net services 2
• Tailor clinical guidelines to individual circumstances, recognizing that family responsibilities may take priority over clinical metrics 2

Documentation Requirements

The comprehensive care plan must be:

• Written and individualized to the specific patient 1
• Completed by the interdisciplinary team including the patient 1
• Signed by all team members and the patient or designee, with documentation if patient chooses not to sign and the reason why 1
• Maintained in the patient's record and updated as clinical status evolves 1
• Communicated interactively with the patient and appropriate family members in collaboration with the primary healthcare provider 3