Care Plans and Care Coordination Terminology
Care planning identifies needs, goals, treatments, and support. Care coordination helps the people and services involved work together across appointments, providers, and settings.
Assessment and planning
- Assessment: A structured review of a person’s health, function, circumstances, and support needs.
- Reassessment: A later review to identify changes and update care decisions.
- Care plan: A coordinated description of care needs, goals, services, monitoring, and responsibilities.
- Treatment plan: A plan describing clinical treatments and how their effects will be reviewed.
- Patient goal: An outcome the patient wants to achieve or maintain.
- Intervention: An action taken to address a health or support need.
- Care team: The people involved in providing and supporting a person’s care.
- Interdisciplinary team: Professionals from different fields working together on care.
- Care conference: A planned discussion to review needs, progress, and next steps.
Coordination and transitions
- Care coordinator: A professional helping organize communication and services across a care plan.
- Referral: A request for another provider or service to assess or support a patient.
- Handoff: Transfer of information and responsibility between professionals or teams.
- Care transition: Movement between care settings, teams, or levels of service.
- Medication reconciliation: Review and comparison of medication information to resolve discrepancies.
- Follow-up: Ongoing review or action after a visit, treatment, referral, or discharge.
- Access barrier: A circumstance that makes obtaining care more difficult.
- Community resource: A local service or organization offering practical, social, or health-related support.
Participation and decision-making
- Shared decision-making: A process in which healthcare professionals and the patient discuss options, evidence, values, and preferences.
- Informed consent: Agreement to a proposed intervention after receiving and understanding relevant information and having an opportunity to ask questions.
- Advance directive: A document recording preferences or appointing a decision-maker for future healthcare circumstances.
- Surrogate decision-maker: A person authorized to make healthcare decisions when the patient cannot do so, under applicable rules.
- Goals of care: The priorities and desired outcomes that guide treatment decisions.
Care-planning processes, professional responsibilities, and decision-making requirements may vary by country, program, and individual circumstances. A member of the care team can explain which plan, responsibilities, and follow-up actions apply to a particular patient.