Documentation/Care Plans
Module guide · Clinical
Care Plans
Templated, multidisciplinary care plans, goals, tasks, the care team, and progress, all tracked in one place per patient.
What this module is for
A care plan is a structured, goal-driven roadmap for a patient's care, built from goals, day-to-day activities, a named team, and progress notes. This module is where that plan is built, assigned, and followed through to completion.
Who uses it
Nurses and care coordinators build and run plans day to day. Attending providers and specialists sign off on them. Supervisors use the analytics view to spot plans that are overdue or need review.
Where to find it
Open Care Plans from the sidebar. Four screens: the full list, your personal worklist, ready-made templates, and an analytics dashboard.
- 1
Care Plans
The hospital-wide list, search, filter, create from scratch, and pull completion reports.
- 2
My Care Plans
Just the plans where you're an active team member, your personal worklist.
- 3
Care Plan Templates
Pre-built plans for common conditions, instantiate one for a patient in a few clicks.
- 4
Care Plan Analytics
Completion rates, category and status breakdowns, and a needs-attention worklist.
Care Plans
The central, hospital-wide list of every care plan on record.
Top bar
| Field | What it means |
|---|---|
| Search | Filters the list live by patient name or plan title. |
| Status pills | All, Draft, Active, On Hold, Completed, Revoked, Entered in Error, Transferred, click to filter the list. |
| Overdue banner | Appears only when at least one plan is past its target date, shows the count. |
Patient Completion Report
Pick a patient in the search box, then Download Completion Report becomes enabled, it produces a PDF of that patient's completed care plans.
"New Care Plan" form
| Field | What it means |
|---|---|
| Patient* | Search by name or MRN. |
| Attending Provider | Optional, search by name or NPI. |
| Title* | e.g. "Type 2 Diabetes Management Plan." |
| Category | e.g. Nursing Care, defaults to Nursing Care. |
| Start Date* | Defaults to today. |
| Target Date | Optional, the date the plan is expected to be complete. |
| Initial Goals | Optional, add one or more: a description, and a Priority of High, Medium or Low. "Add another goal" adds more rows. |
Each row in the list shows the title, patient, category, attending provider, a goal-progress count ("x/y goals"), an OVERDUE pill if applicable, and the status badge. Click any row to open it (see section 6).
My Care Plans
Every plan where you're currently an active team member, a read-only personal worklist.
Same row layout as the main list, but there's nothing to search, filter or create here, it's simply "what am I assigned to right now." If your account isn't linked to a staff record, the page explains there's nothing to show instead.
Care Plan Templates
Pre-built, standardized plans for common conditions, so staff don't have to build a plan from a blank page every time.
| Field | What it means |
|---|---|
| Search templates | Filters the template list live. |
| Template row | Shows the template's name (with "(Inactive)" if retired), category, associated diagnosis if any, and how many times it's been used. |
Instantiate for a patient
Click Instantiate for Patient on any active template, pick the patient in the search box, then Create Care Plan. This creates a brand-new, fully populated plan for that patient from the template's goals and activities, ready to run.
Deactivating a template asks for confirmation
Care Plan Analytics
A read-only dashboard for supervisors and coordinators, quality and workload at a glance.
Stat tiles
| Field | What it means |
|---|---|
| Total Plans | All care plans on record, with how many are currently Active underneath. |
| Goal Completion | Average % of goals completed across plans, with a completed/total count underneath. |
| Activity Completion | Average % of care activities completed, with a count of overdue activities underneath. |
| Unsigned Plans | Plans not yet signed off by a clinician, with how many have a pending review underneath. |
Plans by Category / by Status
Two horizontal bar charts breaking down every plan by category and by status, so you can see at a glance where the workload sits.
"Needs Attention" list
A combined worklist with three colored pills: OVERDUE (amber, past target date), REVIEW DUE (blue, a scheduled review needs completing), UNSIGNED (gray, awaiting a clinician's signature).
Working a Care Plan
Clicking any plan (from the main list or My Care Plans) opens it in a side panel, this is where all the day-to-day work happens, across seven tabs.
Header actions
| Field | What it means |
|---|---|
| Activate / Reactivate | Green button, shown when the plan is Draft or On Hold, moves it to Active. |
| Hold | Shown when Active, pauses the plan. |
| Complete | Blue button, shown when Active, marks the plan finished. |
| Revoke | Red outlined button, shown for any plan not already Revoked or Completed, cancels it. |
| Sign Plan | Shown if not yet signed, records you as having reviewed and signed off. No NPI required, only a name, so nurses, case managers and social workers can sign too. |
| Download PDF | Always available, downloads the full plan. |
None of these open a confirmation popup, each shows a brief loading state and applies immediately.
Tab 1 · Overview
Read-only: Attending, Author, Start/Target Date, Principal Diagnosis, Goal Completion %, who signed it and when, and the Description if one was entered.
Tab 2 · Goals
Add a goal (description, Priority, Target Date). Each goal can be marked Achieved or removed with the trash icon, both immediate, no confirmation.
Tab 3 · Activities
The interventions/tasks that make up the plan: description, Category, Frequency, Due Date, and who it's Assigned To. Each can be marked Complete, Cancelled, or removed. Overdue ones are flagged.
Tab 4 · Team
The multidisciplinary team on this plan: add a staff member with their role (e.g. "Case Manager"); the primary member is tagged. Remove with the trash icon, no confirmation.
Tab 5 · Notes
Free-text progress notes, each shown with author and timestamp. Just type and click Add Note.
Tab 6 · Reviews
Schedule a clinical review (date + type: Initial, Routine, Discharge, Transfer, Urgent). Completing a review requires writing a Review Summary first, it won't save without one.
Tab 7 · Barriers
Obstacles to the patient meeting their goals, financial, transportation, health literacy, language, housing, social support, mental health, substance use, mobility, cognitive, or other, each with a description. Mark Resolved once addressed, no confirmation.
Draft — being set up, not yet in effect
Active — currently guiding the patient's care
On Hold — temporarily paused
Completed — goals met, plan finished
Revoked — cancelled or discontinued
Transferred — handed off, e.g. to another facility
Good practices
Start from a template when one exists
Keep the Activities tab current
Signing doesn't require an NPI