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got a plan, man?

patient-centered care planning in rehabilitation


Level: Beginner-Intermediate

Contact Hours: Contact hours are no longer offered for this course.


Pricing and Licensure

Single User License: $49

Single UNIT License: $345

  • A unit license covers all staff of a single inpatient unit of 0-30 Beds for the life of the course.

Care Plan Course Cover Graphic

Unit, multi-unit and facility pricing/licensure is determined by number of beds. Order Your Copy TodayContact us if your unit has more than 30 beds or if you are interested in multi-unit or facility pricing. For more information on licensure, go to


Course Description

Rehab Nursing Series Course 5

Focus: Meaningful, Individiualized, Interdisciiplinary Care Plans

While care planning is integral to the work of the team, care planning documentation can be a burden for all team members. If systems do not support ease of use, the plan is not integral to care delivery, and/or the plan is not meaningful to the work being done. With many regulatory and accreditation standards tied to care plans, the organization may be at risk if documentation does not support and provide evidence of the excellent work and coordinated care provided.

This course helps to close the gap by reviewing the requirements and purposes of care plans and their components, providing opportunities to practice building elements of the care plan, and by providing suggestions and ideas for creating meaningful care plans that engage patients/family caregivers and the team in documenting the story of goal achievement.


Chapter 1 Overview

Care planning was learned in school but what is really required in the work world of rehabilitation care?  Why do we do what we do when care planning? This chapter provides the rehab nurse with a quick overview of the regulatory, accreditation, and professional expectations for care plan activities and documentation.

  • Do you really have to have a care plan?

  • What components are really required for inpatient rehabilitation care plans?

  • What is the role of evidence-based practice in care plans?

  • How do you integrate standards of care/practice with the requirements for an individualized plan?

Chapter 2 Care Plan Components

This chapter focuses on a review of the components of the care plan, addressing their role in creating meaningful care plans rather than cookie-cutter documentation and busywork that is less meaningful to all involved.

  • Who is the target audience for the care plan?

  • How does the phrasing of problems change the way the patient is presented to the next caregiver?

  • What elements define a meaningful goal?

  • How does the team utilize interventions to promote coordinated interdisciplinary care?

Chapter 3 Care Plan Practice

In this chapter, the learner is invited to practice creating care plan components, evaluating them for effectiveness and considering methods to improve efficiency in creating and maintaining the plan.

  • Does the plan focus the team and patients/caregivers on the knowledge and skills needed to be successful in the next level of care?

  • Is it timely and organized to support learning and practice activities in order to avoid last minute crash course training before discharge?

  • Does your documentation tell the story of the patient’s progress and preparation for discharge?

  • How do you apply these strategies to the documentation system you are required to use?

Chapter 4 Posttest


Learning Outcomes:

As a result of participating in this activity, the learner will be able to pass the posttest with a score of 80% or better, demonstrating knowledge of:

  • Purposes of a current, dynamic, patient-centric, individualized, interdisciplinary plan of care

  • Key components of care planning documentation that should be readily available in the record

  • Expected behaviors for documenting coordination of care with team members

  • Strategies for promoting and designing efficient and effective care planning processes that reduce risks and support transitions in care, competence in self-care management, and continued recovery


Contact hours no longer will be provided for this course after October 1, 2019.If you would like to provide contact hours for this course at your site, contact us at for the details of the Mergener formula.


Return to Rehab Nursing Series.