Advisory AS18/15: Comprehensive Care Standard: Developing the comprehensive care plan

This advisory describes the minimum requirements for Action 5.13 for health service organisations establishing a comprehensive plan.

Advisory details

Item Details
Advisory number AS18/15
Version number 5.0
Trim number D21-4269
Publication date 15 December 2022
Replaces AS18/15 version 4.0 published on 7 October 2020
Compliance with this advisory It is mandatory for approved accrediting agencies to implement this advisory.
Information in this advisory applies to
  • All approved accrediting agencies
  • All health service organisations
Key relationship Comprehensive Care Standard
Attachment Nil
Notes Updated number formatting of the NSQHS Standards actions and timeframes for compliance
Responsible officer Anna Flynn
Director, Partnering with Consumers
Phone: 1800 304 056
To be reviewed December 2024


This advisory describes the minimum requirements for Action 5.13 for health service organisations establishing a comprehensive plan.


The Comprehensive Care Standard requires clinicians to develop and document a comprehensive and individualised care plan for each patient. The application of the comprehensive planning processes uses a risk-based approach. The plan includes information about the patient’s clinical assessment, diagnoses, identified risks, goals of care and preferences. The plan should reflect decisions jointly made by clinicians and the patient, carers, family, and other support people.

Action 5.13 states: Clinicians use processes for shared decision making to develop and document the comprehensive and individualised plan that:

  1. Addresses the significance and complexity of the patient’s issues and risks of harm
  2. Identifies agreed goals and action with the patient’s treatment and care
  3. Identifies the support people a patient wants involved in communications and decision-making about their care
  4. Commences discharge planning at the beginning of the episode of care
  5. Includes a plan for referral to follow-up services if appropriate and available
  6. Is consistent with best practice and evidence.

A comprehensive care plan is a single document or view describing the agreed personal and clinical goals of care. It outlines the key aspects of planned activities for a patient’s care for members of the multidisciplinary team. The plan can be documented on paper in electronic form. An electronic medical record will meet this requirement where it complies with these criteria.

Previous versions of this Advisory required health service organisations to:

  • complete a gap analysis identifying changes that needed to occur in the current care planning processes
  • develop, or refine, organisation-wide policies and processes or templates for delivering comprehensive care plans
  • commence implementation of organisation-wide approach to care planning


By 31 December 2023, health service organisations are to implement an approach to comprehensive care plans that:

  • Uses care plans, pathways and tools endorsed by the organisation
  • Implements models of care that support multidisciplinary care planning appropriate to the patient population and clinical context
  • Ensures the workforce are orientated, educated or trained in the organisation’s approach to care planning
  • Monitors and evaluates the outcomes of the comprehensive care planning processes.

Accrediting agencies are to review evidence to ensure by 1 January 2024, the organisation has:

  • Provided the workforce with access to tools endorsed by the organisation
  • Implemented multidisciplinary comprehensive care planning processes
  • Provided the workforce with orientation, education or training on the comprehensive care planning processes
  • Commenced monitoring and evaluation of the outcomes of its comprehensive care planning processes.

Accrediting agencies are to rate Action 5.13 as met if the organisation demonstrates progress against the specific requirements in the specified timeframe.