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Patient Care Plan

Complete an interactive simulation that includes interviews of a patient, family members, and experienced health care workers. Then, develop a care coordination strategy and a care plan for the patient based on the information gathered from the interviews.


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Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.

Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.

The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions (such as congestive heart failure, pneumonia, asthma, and diabetes) and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.


Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. AHRQ. https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html

Note: Complete the assessments in this course in the order in which they are presented.


As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

· To what extent does a needs assessment support nursing diagnoses?

· Which standards or benchmarks drive outcomes in your current professional practice?

· What action might you take in response to care plan goals or outcomes that are not being met?

To prepare for this assessment, complete the following simulation:

· Vila Health: Care Coordination Scenario I .

In this simulation, you will obtain the information needed to develop a care coordination strategy for Mrs. Snyder and her family. You may use an intervention developed as part of your first assessment. Locate applicable current standards and benchmarks as you determine the best way to develop this strategy.

Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.


Develop a proactive, patient-centered care plan for the patient, using the information gained from your simulated interviews. Focus on care coordination and national care coordination initiatives.

Care Plan Format

Use the  Patient Care Plan Template [DOCX]  provided.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Care Plan

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed.

· Assess a patient’s condition from a coordinated-care perspective.

5. Consider the full scope of the patient’s needs.

5. Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.

. Develop nursing diagnoses that align with patient assessment data.

6. Write two goal statements for each diagnosis.

6. Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific.

6. Consider the psychosociocultural aspect of care.

. Determine appropriate nursing or collaborative interventions.

7. List at least three nursing or collaborative interventions.

7. Provide the rationale for each goal or outcome.

. Explain why each intervention is indicated or therapeutic.

8. Cite applicable references that support each intervention.

. Evaluate care coordination outcomes according to measures and standards.

9. Indicate if the goals were met. If they were not met, explain why.

9. Describe how you would revise the plan of care based on the patient’s response to the current plan.

9. Support conclusions with outcome measures and professional standards.

. Write clearly and concisely, using correct grammar and mechanics.

10. Express your main points and conclusions coherently.

10. Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.

. Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Portfolio Prompt: You may choose to save your patient care plan to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

. Competency 1: Develop patient assessments.

12. Assess a patient’s condition from a coordinated-care perspective.

12. Develop nursing diagnoses that align with patient assessment data.

. Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.

13. Evaluate care coordination outcomes according to measures and standards.

. Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.

14. Determine appropriate nursing or collaborative interventions.

14. Explain why each intervention is indicated or therapeutic.

. Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.

15. Write clearly and concisely, using correct grammar and mechanics.

15. Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

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