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

  • Include a patient and their family in their treatment and discharge goals for this hospitalization
  • Incorporate the patient and family's knowledge, values, beliefs, and cultural backgrounds into the planning and delivery of care
  • Families provide relevant additional or different information
  • Family involvement assists in providing care in hospital, and improves quality and safety of care

Ongoing Assessment

  • Ongoing assessments are done every shift and on an as-needed basis
  • Patient baseline and ongoing 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
  • Patient-reported care needs based on the patient assessment

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
  • Highlighting immediate and current needs of patient that may delay discharge

Safety Huddle

  • Identification of safety issues such as fall risk
  • Identification of safety issues to the patient

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:

When planning care and priorities, consider the following:

  • Issue (e.g. at high risk for falls between 1400h and 1600h)
  • Long and short-term goals (e.g. no falls between 1400h and 1600h, prevent all falls for duration of admission, reduce falls and injuries in the long-term)
  • Interventions and approaches to care - targeted towards goal (e.g. bed alarm, assist to bathroom at 1330h to be proactive, 5P Rounding)
  • Evaluations (e.g. Were there falls between 1400h and 1600h in the last week?, no SIMS reports)

The following are examples that can help guide the care planning process:

  • 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.