Planning of Patient Care

Patient Care Plans are an invaluable tool used by nursing staff to provide quality patient care in a skilled nursing setting. 

Care Plans, in part, make up the clinical record for a given patient.  Care Plans, if created and maintained correctly, should provide a snapshot of the clinical condition it addresses.  A patient care plan should show:

  • All changes in the patient’s condition regarding the particular clinical issue addressed by the plan of care, and;
  • Physician orders and nursing interventions are taken to address each patient’s change of condition in each respective area of care.

In a sense, a care plan is a historical document, which should display an accurate chronology of a given medical condition. Care plans address the specific needs of the residents and will be revised as changes in the residents’ needs are identified. 

Ensuring that Care Plans are updated with all relevant information is critical to maintaining a good clinical record, which ultimately helps the patient by fostering communication between members of the nursing staff in terms of assessing the patient’s progress, the patient’s response to treatment, and changes in the patient’s condition.  The industry refers to this line of communication as CONTINUITY OF CARE.

 The importance of Care Plans has not been lost on California’s legislature.  Title 22 of California’s Code of Regulations requires nursing homes to “develop an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care.” Care Plans must include objectives that are “measurable and time-limited”.

Nursing Homes often neglect patient care plans, failing to update them with changes in the patient’s condition and new physician orders to address those changes.  Nursing homes often claim that Care Plans amount to nothing more than a loosely enforced guideline to assist the nursing staff in managing the care of a patient.  However, without updated, accurate care plans, patients often do not receive the medical treatment needed for their physical health needs due to the all too common breakdown in communication between the members of the nursing staff.

Title 22 CCR §72311(A)(1)(C)(2) states that “Each patient’s care shall be based on [written patient care] plan(s)”.  It is time for the nursing home industry to take this edict seriously.


Title 22 C.C.R.§87457(c)(2), requires these types facility to develop a plan of action by developing the following interventions:

  1. Objectives, within a time frame, which relate to the resident’s problems and/or unmet needs; plans for meeting the objectives.
  2. Plans for meeting the objectives.
  3. Identification of any individuals or agencies responsible for implementing each part of the plan.
  4. Method of evaluating progress.

These facilities which provide a lower level of care compared to SNFs, must perform reappraisals of the services needs required by each resident following significant changes of condition in the resident’s physical or cognitive functioning as required by Title 22 C.C.R. §87463(a)(3).

For residents with dementia, a reappraisal and medical assessments by a physician are required annually to ensure that the facility is still capable of meeting the resident’s care needs. From these reappraisals and medical assessments:

  • the resident’s plan of care is developed and used to the level of care the resident requires
  • to address the level of care and supervision required to protect the resident against health and safety hazards.