Clinical Standardization

Seamless integration of clinical systems to provide collaborative patient-centered care

Improving Care Planning

The purpose of a care plan is to communicate and monitor a person’s progress towards their goals. It facilitates interprofessional collaboration amongst the health care team.

Care plans are developed by the entire health care team in collaboration with the person (patient, client and family). 

Establishing a comprehensive care plan is a dynamic process that is constantly evolving based on the assessment and needs of the person (patient, client and/or family).

Elements of Patient Assessment

Admission Assessment

  • Completed by Registered Nurse (RN) / Licensed Practical Nurse (LPN) / other appropriate interprofessional team member upon admission
  • Incorporates clinical pathway related activities and discharge/ transition planning needs
  • The most appropriate health care professional interprets data findings and completes care plan section
  • Identifying discharge and transition needs based on patient diagnosis, treatment goal and care needs

Patient & Family

  • Patient treatment and discharge goals for this hospitalization
  • Patient information is documented

Ongoing Assessment

  • Ongoing assessments are done every shift and on an as-needed basis
  • Patient baseline and on-going status is re-evaluated using standardized assessment tests (Braden, Morse, etc.)

Best Practice

Evidence-informed care plans are developed taking into consideration:
  • Interprofessional experience and knowledge
  • Relevant policies and procedures, and standards of care

Interprofessional Team Consultation

  • Triggered from admission assessment and bullet rounds

Bullet Rounds

  • Identifying and determining readiness and barriers to patient discharge
  • Determining estimated date of discharge

Safety Huddle

  • Identification of safety issues such as fall risk

Translating to Care Plan

Standardizing and documenting care plans are essential components to facilitate interprofessional communication and collaboration during the provision of care.

The Patient Care Plan Includes

  • Patient plan of care (POC) Kardex
  • Transfer of Accountability (TOA)
  • Progress notes
  • Team white boards/patient white board
  • patient plan of care insert

POC Paper Documentation Guidelines

  • Be brief, concise and objective
  • Use black ink
  • Make it useful
  • Use simple language
  • Do not double document
  • RNs and LPNs collaborate to write POC


Outcomes of care reflect the shared goals of the patient/family and provider. The following are the benefits of establishing a formalized plan of care:

Consistency of care

Accurate and timely communication

Appropriate involvement of interprofessional team

Prevention of harm

Goals of patient and family are met

Timely discharge

Nova Scotia Health Authority (2015). Care Planning 101 [poster]. Interprofessional Practice & Learning.