Overview
The Evaluation section in Care Plan 2.0 enables care teams to periodically review a patient's progress, assess the effectiveness of the current Care Plan, and make necessary updates based on changes in the patient's clinical condition.
Unlike the initial Care Plan creation, an evaluation focuses on determining whether the established goals, interventions, preventive services, and self-management activities continue to meet the patient's needs. Evaluations also help maintain compliance with ongoing care management programs by ensuring the Care Plan remains current and clinically relevant.
Care Plan 2.0 allows evaluations to be performed throughout the life of a Care Plan without requiring users to recreate all clinical information, making ongoing care management more efficient.
Purpose of Evaluations
Evaluations are performed to:
Review patient progress since the previous Care Plan.
Assess the effectiveness of interventions.
Determine whether SMART Goals have been achieved.
Update the patient's clinical information.
Identify new barriers to care.
Document changes in Social Determinants of Health (SDOH).
Review RPM trends and recent assessments.
Prepare the Care Plan for physician review when required.
Regular evaluations ensure the Care Plan evolves alongside the patient's healthcare needs.
Before You Begin
Before starting an evaluation, ensure that:
An active Care Plan already exists.
Recent patient encounters have been documented.
New assessment results are available (if applicable).
Recent RPM or manually recorded vitals have been reviewed.
Medication changes have been documented.
Any hospitalizations or emergency department visits have been recorded.
Navigation
Log in to the HealthArc Portal.
Navigate to Patients.
Select the patient.
Open the Care Plan tab.
Open the active Care Plan.
Select Evaluation from the left navigation menu.
Understanding Care Plan Evaluations
An evaluation is not intended to create a new Care Plan. Instead, it reviews and updates the existing one. During an evaluation, care coordinators determine:
What has improved?
What has worsened?
Which goals have been achieved?
Which interventions remain appropriate?
Are additional services required?
Does the patient's risk level need to change?
The evaluation provides an opportunity to ensure the Care Plan remains individualized and clinically appropriate.
Evaluation Workflow
A comprehensive evaluation should follow a structured review process.
Step 1 – Review Patient Status
Begin by reviewing the patient's overall health since the previous Care Plan. Consider:
New diagnoses
Recent procedures
Hospital admissions
Emergency department visits
Specialist consultations
Changes in functional status
Document any clinically significant updates before proceeding.
Step 2 – Review Assessments
Open the Assessments section and review:
Newly completed assessments
Historical assessment scores
Changes since the previous evaluation
Newly identified concerns
Determine whether additional interventions are needed based on assessment results.
Step 3 – Review Vital Signs
Review the patient's most recent:
Blood Pressure
Weight
Blood Glucose
Pulse Oximetry
Heart Rate
Other available RPM readings
Look for:
Improving trends
Worsening trends
Persistent abnormalities
Missing data
Significant changes should be reflected in updated goals or interventions.
Step 4 – Review Medications
Confirm that:
Medication lists remain current.
Dosages are accurate.
New medications have been added.
Discontinued medications have been removed.
Medication adherence has been assessed.
Medication changes frequently require updates to the Care Plan.
Step 5 – Review SMART Goals
Open the SMART Goals section. For each goal, determine whether it is:
Completed
In Progress
Partially Achieved
No Longer Applicable
Requires Revision
Goals should reflect the patient's current health priorities. Examples:
Blood pressure goal achieved
Weight loss progressing
Smoking cessation unsuccessful
Medication adherence improved
Update each goal accordingly.
Step 6 – Review Interventions
Evaluate every intervention. Determine whether it should:
Continue
Be modified
Be discontinued
Be replaced
Be expanded
Interventions should remain aligned with current clinical needs.
Step 7 – Review Self-Management
Discuss the patient's participation in self-management activities. Examples include:
Medication adherence
Home blood pressure monitoring
Blood glucose logging
Exercise
Diet modifications
Smoking cessation
Document successes and challenges.
Step 8 – Review Preventive Services
Verify whether recommended preventive services have been completed. Examples:
Annual Wellness Visit
Vaccinations
Mammogram
Colon Cancer Screening
Diabetic Eye Exam
A1C Testing
Update completion status where appropriate.
Step 9 – Review SDOH
Social circumstances often change over time. Review:
Housing
Transportation
Financial stability
Food security
Caregiver support
Insurance status
Update documentation if changes have occurred.
Step 10 – Review Risk Classification
Determine whether the patient's risk category should change based on:
Clinical improvements
New diagnoses
Hospitalizations
Medication changes
SDOH changes
RPM trends
Update the Risk Classification if necessary.
Step 11 – Document Evaluation Notes
The Evaluation section provides an opportunity to summarize the patient's overall progress. Include information such as:
Overall clinical improvement
Remaining concerns
Goals achieved
Goals requiring continued monitoring
Newly identified risks
Recommended follow-up
These notes provide valuable context for future evaluations and physician review.
Scheduling Future Evaluations
Following completion of an evaluation, determine the appropriate follow-up schedule based on the patient's condition and organizational protocols. Evaluation frequency may vary depending on:
Clinical complexity
Program enrollment
Provider recommendations
Recent hospitalizations
Risk Classification
Patient engagement
Higher-risk patients may require more frequent evaluations than patients with stable chronic conditions.
Updating the Care Plan
An evaluation may result in updates to several Care Plan sections, including:
SMART Goals
Interventions
Self-Management Tasks
Preventive Services
Risk Classification
Care Team Notes
Physician Review Requirements
Ensure all related sections are updated before finalizing the evaluation.
Completing the Evaluation
Once all reviews have been completed:
Verify that all updates have been saved.
Review the Care Plan for completeness.
Confirm that evaluation notes accurately summarize the patient's progress.
Save the Evaluation.
Proceed to physician review if organizational workflow requires provider approval.
Best Practices
Perform evaluations consistently according to your organization's care management schedule.
Compare current findings with previous evaluations to identify trends.
Engage the patient during the evaluation whenever possible.
Update only sections affected by changes in the patient's condition.
Clearly document the rationale for modifying goals, interventions, or risk classification.
Review RPM data before finalizing the evaluation.
Coordinate with providers if significant clinical changes are identified.
Common Evaluation Scenarios
Patient Showing Improvement
A patient with hypertension has maintained normal blood pressure readings for three consecutive months.
Recommended Actions
Update the goal status.
Continue successful interventions.
Reinforce medication adherence.
Consider reducing follow-up intensity if clinically appropriate.
Patient Condition Worsening
A diabetic patient reports increasing blood glucose levels and recent hospitalization.
Recommended Actions
Update assessments.
Modify SMART Goals.
Add additional interventions.
Increase follow-up frequency.
Reassess Risk Classification.
Notify the provider if necessary.
New Social Challenges
The patient reports loss of transportation and difficulty obtaining medications.
Recommended Actions
Update the SDOH section.
Add transportation-related interventions.
Refer the patient to community resources.
Review medication adherence.
Troubleshooting
I cannot edit the Evaluation section.
Verify that the Care Plan is still in an editable state and that your user role includes permission to update evaluations.
Do I need to create a new Care Plan for every evaluation?
No. Evaluations are intended to update the existing Care Plan. A new Care Plan is generally created only when required by your organization's workflow or program requirements.
Can I modify goals during an evaluation?
Yes. Evaluations are the appropriate time to review, update, complete, or discontinue SMART Goals based on the patient's progress.
How often should evaluations be completed?
Evaluation frequency depends on the patient's clinical condition, enrolled program, provider recommendations, and your organization's care management protocols.
Should every evaluation include a Risk Classification review?
Yes. Risk Classification should be reassessed during each evaluation to ensure it reflects the patient's current health status.