Essential element 4: Develop a single comprehensive care plan

A comprehensive care plan is a document describing agreed goals of care, and outlining planned medical, nursing, midwifery and allied health activities for a patient. A single comprehensive care plan should be prepared for a patient so that core information can be shared, accessed and acted on by all members of the multidisciplinary team.

Comprehensive care plans reflect shared decisions made with patients, carers and families about the tests, interventions, treatments and other activities needed to achieve the goals of care.

There is a substantial amount of information that could be included within a comprehensive care plan; however, if all relevant information were included the plan could become unwieldy and may deter use. Information that should be included within a comprehensive care plan can be grouped into eight components including:

  • Clinical assessment and diagnosis
  • Goals of care
  • Risk screening and assessment
  • Planned interventions
  • Activities of daily living
  • Monitoring plans
  • People involved in care
  • Discharge planning.

Resources

The Commission has developed resources providing guidance on the type of information that could be included in a comprehensive care plan.