CLN-SOP-002: Individualised care planning

Organisation name Site or unit		Standard operating procedure Individualised Care Planning
Document ID	CLN-SOP-002-EN	Version	1.2
Status	To be issued	Issue date
Review date		Replaces	1.0
Owner	Clinical lead for this procedure	Approved by
Classification	Internal	Applies to	All clinical areas
Signature

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

1. Purpose	2
2. Scope	2
3. Definitions	2
4. Background	2
5. Responsibilities	3
6. Materials and equipment	3
7. Safety and exceptions	3
8. Procedure	3
9. Worked example	4
10. Decision points	5
11. Escalation	6
12. Monitoring and compliance	6
13. Records	6
14. Training and competence	6
15. Related documents	6
16. References	6
17. Change history	6
Abbreviations	1
Annex A. Care plan audit record	7
Annex B. Monitoring chart	7

Abbreviations

Abbreviation	Meaning
MDT	Multidisciplinary team
SOP	Standard operating procedure

Key points

Every patient has an individual care plan, built from the admission assessment, within the first day of care.
Each problem in the assessment has a goal that can be measured, an intervention, a named person responsible, and a review date.
The patient, and family where appropriate, take part in setting the goals, and their views are recorded.
The plan is reviewed at each review date and at every change in condition, and the review is recorded.
Stop and get help straight away if a patient has no individual care plan after the first day of care.

Purpose

To make treatment fit the patient, and to state clearly what the treatment is trying to achieve, so that progress can be judged. A generic plan does not fit the patient and guides nobody. This SOP sets out how a plan is written from the assessment, how goals are made measurable, how the patient is involved, and how the plan is kept up to date. It supports criterion 1.3.

Scope

Element	Coverage
Who	Responsible clinicians who write the plan, nurses and therapists who deliver it, and the patient and family.
Where	All wards, clinics and departments of the facility.
When	Within the first day of care; at each review date; and at any change in the patient’s condition.
Not covered	Time-limited emergency treatment, which is covered by the emergency procedure, and the discharge summary.

Definitions

Term	Meaning
Individual care plan	The written plan for one patient: the problems, the goals, the interventions, the responsible person, and the review date for each.
Measurable goal	A goal that states a target and a time, so that it can be checked. For example: “walk 20 metres with a frame by discharge” rather than “improve mobility”.
Responsible clinician	The doctor or nurse who writes and updates the plan.
Review date	The date by which the plan must be looked at again, set for each problem.

Background

A plan written from a generic template, or never updated, does not describe what is happening to the patient. An individual plan that uses the assessment, sets measurable goals, involves the patient, and is reviewed is the basis for judging whether treatment is working. The same plan is also what the team hands over when the patient moves between wards or leaves.

Responsibilities

Role	Responsibility
Clinical director	Approves this SOP and the plan template, and receives the quarterly audit.
Responsible clinician	Writes the plan, sets the goals, and updates the plan at each review.
Ward nurse	Delivers the planned care, records progress against each goal, and reports any problem with the plan.
Allied health professionals	Write the interventions for their discipline into the plan and review them.
Patient and family	Take part in setting the goals, and tell the team if a goal no longer fits.

Materials and equipment

Item	Requirement
Care plan form	The facility’s current approved form, with a row for each problem, goal, intervention, responsible person, and review date.

Safety and exceptions

Urgent treatment first. Do not delay urgent treatment to complete the plan. The plan follows as soon as the patient is stable, and within the first day of care.
Patient cannot take part. Set the plan with the family or the nominated decision-maker, record the reason the patient could not take part, and review it when the patient can.
Disagreement. Where the patient or family disagrees with a goal, record their view, explain the clinical reasons, and agree the plan or record that it has not been agreed.

Procedure

Before you start

Read the admission assessment and any existing plan.
List the problems identified in the assessment. Each problem needs a goal.

Step 1. Write a goal for each problem

State the goal for the problem in terms the patient can understand.
Make the goal measurable: name what will be different, by how much, and by when. Example: “Pain score 3 or less at rest by day 3”, “Eats at least half of each meal by day 5”, “No fall in the next 4 weeks”.
If a goal cannot be measured, record the best measure available (for example, the patient’s own description with a scale) and say how it will be checked.

Step 2. Choose the interventions and the owner

For each goal, write the intervention, the frequency or dose, and the person responsible.
Include the interventions that link to the other SOPs: falls (PSF-SOP-001-EN), pressure care (CLN-SOP-004-EN), nutrition (CLN-SOP-003-EN), VTE (CLN-SOP-005-EN).
Where an intervention needs an allied health professional, record the referral.

Step 3. Agree the plan with the patient

Explain the plan in plain language. Ask the patient what matters most to them and whether each goal makes sense.
Where the family is involved, with the patient’s agreement, include them. Record the views of each person.
Record the outcome: agreed, agreed in part, or not agreed, with the reason.

Step 4. Review and update

Review each goal on its review date. Record progress as met, partly met, not met, or no longer relevant.
Update the plan at every change in condition, and when a goal is met, not met, or no longer relevant.
Where a goal is not met after two reviews, reassess the cause and change the intervention, and record the change.

Worked example

Situation	What to do
A 69-year-old woman after a bowel operation. Her assessment shows pain, poor mobility, and reduced intake.	Three problems, three goals. Pain: “pain 3 or less at rest and able to walk to the bathroom by day 2”. Mobility: “walks 10 metres with a frame by day 3, with physiotherapy” (intervention and owner recorded). Intake: “eats at least half of each meal by day 4” (nutrition referral linked to CLN-SOP-003-EN). Her daughter is involved at her request, and her views are recorded. The plan is reviewed on day 2, when the pain goal is partly met, and the analgesia is changed.
The plan on the record has not been updated for five days, and the patient has had a fall.	Treat as a change in condition: review the plan at once, update the goals and interventions, inform the responsible clinician, and record the fall under PSF-SOP-001-EN.

Situation

What to do

A 69-year-old woman after a bowel operation. Her assessment shows pain, poor mobility, and reduced intake.

Three problems, three goals. Pain: “pain 3 or less at rest and able to walk to the bathroom by day 2”. Mobility: “walks 10 metres with a frame by day 3, with physiotherapy” (intervention and owner recorded). Intake: “eats at least half of each meal by day 4” (nutrition referral linked to CLN-SOP-003-EN). Her daughter is involved at her request, and her views are recorded. The plan is reviewed on day 2, when the pain goal is partly met, and the analgesia is changed.

The plan on the record has not been updated for five days, and the patient has had a fall.

Treat as a change in condition: review the plan at once, update the goals and interventions, inform the responsible clinician, and record the fall under PSF-SOP-001-EN.

Figure 1. Care planning cycle

Decision points

If	Then
No plan after the first day	Escalate immediately to the responsible clinician.
A goal is not met on review	Review the intervention; change it and record the change.
Patient or family disagrees with a goal	Record the view, explain the reasons, and agree or record that it is not agreed.
Change in condition	Review and update the plan at once.

Escalation

Event	Inform	Timescale
No individual care plan after the first day	Responsible clinician and ward or unit manager	Immediately
Plan not reviewed on the due date	Ward or unit manager	Same shift
Repeated gaps on one unit	Clinical director and quality team	Within one week

Monitoring and compliance

Indicator	Target	Method	Frequency	Owner
Patients with a plan within the first day	100% of patients	Audit of 20 records per unit	Monthly	Ward manager
Goals written as measurable	100% of goals	Audit of 20 plans per unit	Monthly	Clinical lead
Plans reviewed on the due date	100% of plans	Audit of 20 records per unit	Monthly	Ward manager

Records

Record	Kept in	Retention
Individual care plan and reviews	Patient record	As set by the institutional retention policy

Training and competence

Induction: writing measurable goals, linking interventions to the assessment, and using the plan form. Competence is assessed by rewriting three vague goals as measurable goals.
Annual update: audit of care plans against this SOP.

ID	Title	Relationship
CLN-SOP-001-EN	Structured clinical assessment on admission	Source of the plan
PSF-SOP-001-EN	Falls Risk Assessment and Prevention	Falls interventions
CLN-SOP-004-EN	Pressure injury risk assessment and prevention	Skin interventions

References

ASF Accreditation Standards, Standard 1 (Assessment, Care Planning and Safety), criterion 1.3. No external clinical guideline was cited; the goal-setting method is local practice and must be confirmed by the clinical director.

Change history

Version	Date	Summary of change	Approved by
1.0		First approved version.	ASF Expert Committee
1.2		Substantive revision: measurable-goal method with examples, linked interventions, patient and family agreement steps, review rules and worked example.

Annex A. Care plan audit record

Use this record for each audit session. Record one line per patient or task observed. Enter Y, N or NA as shown in the column heading.

Date	Unit	Patient reference	Plan in place after day 1 (Y / N)	Measurable goals (Y / N)	Patient or family involved (Y / N / NA)	Reviewed on due date (Y / N)	Comment

Annex B. Monitoring chart

The unit records its monthly result on this chart and reviews it at the monthly meeting. Plot each month as a point or a bar, and note the actions taken beside it.

Figure B.1 Care plans in place and reviewed by month. Target as set by the facility (see the monitoring table).

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