The way that comprehensive care is delivered should be reviewed at the end of the care episode but it may also need to be reviewed during the episode of care if there are changes in the patient’s condition, expectations, needs, diagnoses or prognosis, or if the care plan is ineffective.

Patients will require different health care depending on their individual needs, preferences and goals. It is important that care is provided continuously and collaboratively in line with the patients' diagnoses, agreed goals of care and the comprehensive care plan.

A single plan (one document or digital view) is not a requirement. However, each patient should have a comprehensive plan for care developed relevant to their care needs.

As well as identifying clinical issues, risk screening and assessment processes can help identify the likelihood of harm, and support decision making about treatment and risk mitigation.

The purpose of identifying and agreeing to goals of care is to develop a shared understanding between patients, family, carers, other support people and the clinicians in the multidisciplinary team.